Access to the pediatric medical chart

Definition of the Medical Chart:

The medical chart contains different documents and reports* regarding a patient’s health. These documents are available in the paper chart or on electronic support, in certain cases.

*(X-rays, photos, Pathology strips, ECG and EEG tracings)

To Whom to Address my Request

The request should preferably be done in writing and sent to the Medical Records Department:

By mail:
Medical Records
Montreal Children’s Hospital
1001 Decarie Boulevard, Room C.RC.7103
Montreal, Quebec H4A 3J1

By Fax:
(514) 412-4240

On site:
Room C.RC.7103
Opening Hours:
8:00 A.M. → 1:00 P.M.
2:00 P.M. → 4:00 P.M.

Monday to Friday

To be accepted, what should I include in my request?

Family name and first name of the patient
Birth date
Parents’ full names
Hospital unit number, if possible
Exact information you are looking for. Art. 42 Loi sur l’Accès aux documents des organismes publics et sur la protection des renseignements personnels
For whom the information is for
Family name and first name
Full address or Fax number (in case of emergency)
Signature of the person authorized to make the request

Who must sign the request?

Art. 53 Loi sur l’ Accès aux documents des organismes publics et sur la protection des renseignements personnels et LSSSS Art. 12, 21, 22, 23 [1]

1- Patient less than 14 years of age:

The parents (father or mother)
Legal guardian
DYP

2- 14 to 18 years of age

The patient himself/herself
The parents of a mentally deficient person
Legal guardian
DYP
Close relative of an incapable user

3- Patient 18 years of age or over

The patient himself/herself
Legal guardian or representative
Close relative of an incapable user
Person carrying out a mandate for an incapable person 18 years of age or over
Person showing a particular interest in the incapable user of 18 years of age or over

The Fees

The first twenty (20) pages (paper) are at no cost.

Any supplementary page is subject to the decree published once a year in the Gazette officielle.

Certificates

A birth or death certificate can be obtained from the Registrar of Civil Status 2050 Bleury, Montreal, Qc H3A 2J5
Tel: (514) 864-3900 or in Quebec City Tel:(418) 643-3900. Their web site is: www.etatcivil.gouv.qc.ca [1].

The hospital can provide an Attestation of Birth/Death.

A charge of $15.00 is applicable (plus $2.00 for each additional copy).

Blood Type and Vaccinations

Blood types are not given over the telephone. The same process as a request for access applies.

Concerning vaccinations, only tetanus vaccination information is available by telephone. For all other vaccinations, they follow the same process as a regular request for access.

Adoption

No information regarding biological parents can be released.

Requests must be directed to Youth Centers, Adoption sector.

Deaths

At the time of a death, the medical chart falls under specific articles of law, which limit access to the medical chart.

LSSSS, Art. 23 [1]

Right to Ask for Corrections

Any patient finding an error of fact in a specific situation in the medical chart can ask for a correction to be made.

Loi sur l’Accès aux documents des organismes publics et sur la protection des renseignements personnels, Art. 89 and CC du Québec, Art. 40 [2]

Chart Consultation on Site

It is possible, on appointment with Medical Records, to consult your own medical chart. There is no charge for this consultation.

Loi sur l’accès aux Documents des organismes publics et sur la protection des renseignements personnels, Art. 83, 84 and 85

How long does a chart remain accessible?

The medical chart remains accessible in whole or in part, for the duration of time foreseen by the Record Registry of each establishment.

Acces refused/Request for Revision

Art. 27 LSSSS [1] and Art. 18 LSSSS [1]

[1] Loi sur les services de santé et les services sociaux

[2] Code Civil du Québec

Project graciously subsidized by the MUHC Patients’ Education Committee.

Prepared by: Chantal Desmarais and Christianne Tessier, Medical Librarians.