The right of access covers more than most people think. It is worth knowing exactly how much – before someone asks for it.

You are writing a note after a consultation that was a bit difficult. The patient was frustrated, you were behind schedule, and you phrased yourself quickly. «The patient appears unmotivated.» It is a clinical observation. It is also a sentence someone is going to read in three weeks, sitting at their own kitchen table.

Access to public records is not an exception. It is the general rule, and it has been for a long time. But very few of us have read the rules properly, and it is easy to have a somewhat too narrow idea of what they actually cover.

The main rule: everything, not just the notes

Section 41 of the Health Personnel Act requires healthcare personnel and entities in the health and care services to provide access to medical records to those who have the right of access. The Directorate of Health formulates the purpose as follows: the right of access is intended to give patients the opportunity to safeguard their interests, and is a means of realizing the right to information and participation – as well as the right to appeal or seek patient injury compensation.

The patient has the right to access their medical record with attachment, and upon request, the right to a copy. And this is where many get it wrong: the starting point is access to all information in the medical record. This also applies to audio logs, X-rays, and video recordings. Material that is stored for reasons such as quality assurance in the enterprise is also covered, pursuant to Section 11 of the Medical Records Regulations.

Section 11 of the Health Personnel Act / Section 11 of the Medical Records Regulations adding two practical things that are good to be aware of: access must be Free, and the data controller must facilitate the right of access for Sami speakers, foreign language speakers, and persons with disabilities. If the patient requests multiple copies, a reasonable fee based on administrative costs may be charged – but not for the access itself.

Furthermore, for the right of access to be genuine, healthcare personnel must, upon request, explain technical terms. It is a small requirement with a major consequence: your medical record must, in practice, be translatable into something the patient understands, by you.

Age limits, in short

The starting point is that all patients over the age of 16 have an independent right of access to their own medical records. Children between the ages of 12 and 16 have a certain degree of independent right of access. Children under the age of 12 do not have a right of access themselves, but parents or others with parental responsibility have the right of access on behalf of the child.

It is not a technical detail. For public health nurses, general practitioners, and everyone who meets youth, that boundary determines how you phrase what is to be written – and what you may need to discuss with the young person before you write it.

When access can be denied – and how narrow it is

There are exceptions, but they are narrower than many assume. The Norwegian Directorate of Health's commentary on Section 5-1 of the Patients' and Users' Rights Act describes two bases: where there is urgently needed to prevent the risk of loss of life or serious injury to the patient themselves, or where access to medical records is clearly inadvisable out of consideration for those close to the patient.

The choice of words is not accidental. «Compellingly necessary» and «clearly ill-advised» are strict thresholds. They are not intended to cover situations where the content is merely unpleasant to read, or where the healthcare personnel would have phrased things differently in hindsight.

The duty of confidentiality also applies to the patient in these cases, and breach of statutory confidentiality is punishable by law. That is one of the reasons why the assessment must be made, and documented, and not left to a gut feeling at the reception desk.

What this means for how you write

The right of access does not change what should be in the public journal. It changes how it is wise to phrase it.

A note must still contain the clinical observations, diagnostic considerations, and the rationale for what you did. What is worth considering is the difference between an observation and a characterization. «The patient missed three scheduled appointments» is an observation. «The patient is uncooperative» is an interpretation that the patient can read—and which is difficult to argue against afterward because it does not state what it is based on.

Section 10 of the Medical Records Regulations recalls something related to this: the recording must take place without undue delay after the healthcare has been provided, and must be dated and signed. Notes written late in the evening from memory often become shorter and more categorical than they should be. Not because anyone is sloppy, but because the details are gone and only the impression remains.

We have written previously about how your journal entry is often read in a completely different place than where you wrote it. The right of access adds one more reader: the patient themselves.

The Medivox is recording

Medivox transcribes the clinical conversation into text and structures it according to templates you build yourself. The most practical effect for this topic is the timing: the note is created right after the consultation, while you still remember what was actually said, not late at night when only an impression remains.

It usually yields more precise notes, not more comprehensive ones. Concrete observations instead of summarizing characteristics – which also stands up best if the patient one day requests access to their records. Psychologists know this balancing act particularly well, the note must be both professionally adequate and readable for the person it concerns.

All data is pseudonymized before further processing, and all data processing takes place in Norwegian data centers. You own the medical record and make the final assessment. Medivox documents the assessment you have already made.

A simple question to take away

You do not need to write for the patient. You are writing for the next clinician, and for yourself in three years.

But there is a simple test that rarely makes a note worse: would you be able to explain this sentence to the patient, face to face, without qualifying it? If the answer is no, it is often not the right of access that is the problem – it is the phrasing.

Frequently Asked Questions

Does the patient have the right to view everything in their medical record? The starting point is yes. The right of access covers all information in the medical record, including attachments such as audio logs, X-rays, and video recordings. The exceptions are narrow and require a specific assessment.

Does it cost anything to access one's medical records? No. Section 11 of the Medical Records Regulations states that access shall be free of charge. If the patient requests multiple copies, a reasonable fee based on administrative costs may be charged.

From what age can children view their own medical record? Patients over 16 years of age have the independent right of access. Children between 12 and 16 years of age have a certain degree of independent right of access, while parents have the right of access on behalf of children under 12 years of age.

Can I deny a patient access if the content is distressing? The threshold is high. Access can only be denied when it is urgently necessary to prevent danger to life or serious harm to the patient's health, or when access is clearly inadvisable out of consideration for next of kin.

Do speech-to-text notes make them more or less suitable for inspection? Dictation is the core function in Medivox, and its primary effect is that the note is written while the conversation is fresh. This usually results in more specific formulations—and specific formulations withstand scrutiny better than summarizing characteristics.

Use Medivox for free – Get started completely free

Are you wondering how your note template can be set up so that it both covers the duty to document and withstands being read? Contact us – we will go through the setup with you, with no binding period.

Sources: