RULES AND RIGHTS

Patient records

Patientjournalen - engelskaThe content concerns Västerbotten

A record is made when patients seek and receive care. The primary purpose of patient records is to ensure that your healthcare is documented by the staff member who administers your care.

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The records become a source of information for continued care, for example, in the treatment you receive. Patient records can also help you to take a more active role in your care.

Patient records are also important

  • if you have a complaint about your care and want an investigation to be carried out
  • because they help to monitor and develop care activities
  • because they can be used for research under certain conditions.

All staff members who are licensed healthcare professionals must write down their assessments, actions, etc. in the patient's records. Some professionals who are not licensed healthcare professionals are also required to keep records. These include, for example, some counsellors and staff members assisting licensed healthcare professionals.

Read your records online

Patients who have been cared for within Västerbotten County Council can read their records online. You can access your records with electronic identification (e-legitimation) on the 1177.se website.

The records contain the notes taken by the healthcare professional when you visited a healthcare centre, were hospitalised or spoke to a healthcare professional nursing home on the phone. In the long term it will also be possible to see referrals and view your test results.

You can read your patient records from 2001 onwards online. Records made prior to 2001 are available on paper. Notes from forensic psychiatry, adult psychiatry, child and adolescent psychiatry, clinical genetics, child and adolescent rehabilitation and youth clinics are neither available in the e-service.

Your records on paper

If you would like to read your records on paper please contact the place where you were treated. You can phone or write to the staff member who treated you and ask to see your records. Healthcare providers have a duty to answer you as soon as possible. If you feel that their answer is taking too long please contact the healthcare provider’s manager.

When records are not released

Healthcare providers always complete an individual assessment to decide whether records should be released. For example, you may be denied access to your medical records if the treating doctor believes that there are compelling medical reasons why you should not read them. This happens very rarely, and usually only in psychiatric care cases.

Patient records are protected

Only the health and medical care staff responsible for your treatment, or other staff that require the information for their work in health and medical care services, have the right to access your records.

Every time a healthcare professional accesses your records this is documented. You have the right to know if and when a staff member has accessed your records. For information on when a healthcare professional has accessed your records, you must contact the healthcare provider who treated you and ask for a log excerpt. The log excerpt should be modified so that you can easily see which care unit viewed the records and when this occurred.

Connected record keeping

Connected record keeping means that different healthcare providers, for example the County Council and a private healthcare provider, share patient records with each other. If you receive care with a new healthcare provider, the medical staff there can access information such as previous test results, medication and treatments.

Healthcare professionals should inform you if the healthcare provider shares patient records with others. You are entitled to decline your individual details being made available to other healthcare providers.

If the healthcare provider wishes to obtain patient records from another healthcare provider, patients must be contacted for their consent.

If you wish to block information

If you wish to block information in your records so that it is not included in connected record keeping, you can download a blocking form at 1177.se/patientjournalen. You can also phone 090-785 70 04 and ask to speak to someone regarding blocking patient records.

If you block your information from other healthcare providers, they cannot access the information. You must then update your new healthcare contacts with the information they need. Blocking your records can mean that healthcare professionals do not have a complete picture. This may jeopardise patient safety and affect the outcome of the care and treatment you receive.

Healthcare professionals can access blocked patient records without consent in some circumstances. This applies, for example, if you are unconscious.

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