After every visit, keep your own copy of your medical records, test reports and imaging
- Moderate value
- Evidence A
- Saves money
- Free
- Takes minutes
- Some willpower
In plain words
Reading and copying your own medical records is a right the law gives you. Outpatient records, inpatient notes, lab reports, imaging, surgery and anesthesia records, pathology materials and itemized bills can all be copied. Hospitals have a dedicated window for this and may charge only the cost of copying. Changing hospitals, getting a second opinion, filing a commercial insurance claim, and any real dispute all depend on this stack of papers.
- Cost
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Free. The hospital may charge a copying fee at cost under the rules, and its fee schedule must be public. The hard part is remembering to get a copy after every visit.
- What you get
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The regulations expressly list reading and copying medical records as a patient's right. The scope covers all materials, including outpatient records, inpatient notes, lab reports, medical imaging, surgery and anesthesia records, pathology materials and medical bills. Changing hospitals, getting a second doctor to look again, filing a commercial insurance claim and any real dispute all rest on these.
- Notes
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There is a dedicated window for copying; you don't need to ask the doctor. For the list of what you can copy, just read Article 16 of the Regulations on the Prevention and Handling of Medical Disputes (《医疗纠纷预防和处理条例》). First come outpatient records, inpatient notes, temperature charts, doctor's orders, lab reports and imaging. Then surgery and anesthesia records, pathology materials, nursing records and itemized medical bills. Once you have them, file them in one folder in date order. The most important items are the discharge summary, the surgical record, the pathology report and the key images. For a chronic illness, record each round of measurements in the same notebook; see §16.
- Evidence grade
- A : Specific numbers from meta-analyses, large cohorts or randomized trials; for law and policy, the statute or official text.
- Sources
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- 国务院 (2018). 医疗纠纷预防和处理条例（国务院令第 701 号）第十六条：「患者有权查阅、复制其门诊病历、住院志、体温单、医嘱单、化验单（检验报告）、医学影像检查资料、特殊检查同意书、手术同意书、手术及麻醉记录、病理资料、护理记录、医疗费用以及国务院卫生主管部门规定的其他属于病历的全部资料。」「患者要求复制病历资料的，医疗机构应当提供复制服务，并在复制的病历资料上加盖证明印记……可以收取工本费，收费标准应当公开。」「患者死亡的，其近亲属可以依照本条例的规定，查阅、复制病历资料。」第十五条「任何单位和个人不得篡改、伪造、隐匿、毁灭或者抢夺病历资料。」https://www.gov.cn/zhengce/zhengceku/2018-08/31/content_5318057.htm
- 国家卫生计生委、国家中医药管理局 (2013). 医疗机构病历管理规定（2013 年版）：医疗机构「应当指定部门或者专（兼）职人员负责受理复制病历资料的申请」，复制在申请人在场的情况下进行并加盖证明印记. http://www.gov.cn/gongbao/content/2014/content_2600084.htm
Mentioned in
- Go for follow-up checks at the interval your doctor sets, and record every result in the same notebook
- If you have doubts about your care, ask on the spot to have the records sealed, with both sides present, an inventory made, and each side keeping a copy
- Wait until treatment has ended to have a disability assessment; done too early, the grade will be rated too low
- To thank a doctor who saved you, use a thank-you letter, a pennant and a satisfaction rating, not a red envelope: the code bans gifts of money and goods, not gratitude
Translated from the Chinese original. Original book, section 24, tip 5. This section is about health and medicines. It is general information, not a substitute for a doctor’s diagnosis or prescription. Content may be out of date and rules differ by place. When you actually deal with an agency, a doctor or a court, follow what local officials, doctors and lawyers tell you. Disclaimer