ACCORDING TO A JUDGMENT OF THE COURT OF JUSTICE OF THE EUROPEAN UNION, A PATIENT HAS THE RIGHT TO OBTAIN A FIRST COPY OF HIS MEDICAL RECORD FREE OF CHARGE

#106According to a judgment of the Court of Justice of the European Union, a patient has the right to obtain a first copy of his medical record free of charge

A patient in Germany asked his doctor for a copy of his medical record on the grounds that he wanted to hold his doctor liable for errors made by the doctor in providing treatment to him. However, the doctor refused to give him a copy of the medical record without paying the fee for providing him with a copy of the medical record.

The patient brought an action before the German Federal Court on the ground that he believed he was entitled to obtain a copy of his medical record free of charge. The German Federal Court referred the matter to the Court of Justice of the European Union for a preliminary ruling. The German Federal Court held that the resolution of the dispute depended on the interpretation of the provisions of European Union law, namely the General Data Protection Regulation (GDPR).

In its judgment, the Court of Justice of the European Union stated that under the General Data Protection Regulation (GDPR), a patient has the right to obtain a copy of his or her medical record free of charge. For the reason that a doctor who provides a patient with a copy of a medical record can be considered a person responsible for the processing of his patient's personal data under the General Data Protection Regulation (GDPR). The doctor, as the data subject, is obliged to provide the patient with the first copy of the medical record free of charge, even without justification by the patient as to the purpose for which he or she requires the said copy of the medical record.

The doctor may only charge the patient a fee for the issue of a copy of the medical record if the patient has already received a first copy of his medical record free of charge and requests it again. For the reason that, even with a view to protecting the economic interests of treating persons, national legislation cannot impose a charge on a patient for the first copy of his medical record.

In conclusion, the patient has the right not only to be provided with a free copy of his medical record for the first time, but also the right to obtain a complete copy of all documents contained in his medical record if this is necessary for an understanding of the personal data contained in those documents. This right of patients includes, in particular, data in the medical record containing information such as the diagnosis, the results of examinations, the opinions of the attending physicians and any treatment given or interventions carried out on it.