Everyone has the right to read their medical record

As a resident of a nursing home, you have the right to access your medical record. The manager or medical officer can make a harm assessment, but there must be very strong reasons for you not to be allowed to access the record. If the facility denies access, one can turn to the Health and Social Care Inspectorate (IVO) to assert their rights.

Relatives do not have the same right to request the medical record, but can often claim the right to access the record for a person in a nursing home. Especially if the resident has difficulty voicing their own interests. Information about a resident can thus be disclosed if there is no doubt whatsoever that the resident or relatives suffer harm from the information being disclosed. When such an assessment is to be carried out, the starting point must always be the individual's situation.

Be mindful of how you write, it's the resident's medical record

Medical records should be factual and based on what actually happens in the operation. There is no room for subjective opinions. Sometimes, those who review a record may find that it contains a whole novel of irrelevancies. Other times, the only note for several months is that the resident slept at night. These are clear signs that the documentation is not functioning on the unit.

The record should also be written in comprehensible Swedish. Handwritten records can sometimes consist of more or less incomprehensible scribbles, and even typewritten records can be difficult to understand at times. With that said, we can probably still determine that most records are well written, and it's possible to see a context and understand how the care was planned and implemented.

Document carefully in case of deviations

One occasion when it might be of interest to read your medical record is after a healthcare injury. Something may have happened that caused unnecessary suffering. You may be considering claiming compensation from patient insurance or the nursing home's liability insurance.

It's also good to know that there are three different records at the nursing home. Nurse Assistants document in a social record and work from an implementation plan. Nurses, occupational therapists, and physiotherapists make care plans or health plans and document in a health and medical care journal. Then there is the doctor who is employed by the region and documents in the primary care journal system.

Care personnel:
- Are you satisfied with the social documentation that you and your colleagues at the unit write?
- Do you remember that it's the resident's record when you write?

Manager, nurse, occupational therapist, and physiotherapist:
- Is your documentation objectively and factually written?
- Have you ever felt uncomfortable when a resident or relative has requested extracts from your documentation?

Residents and relatives:
- Have you been in situations where you have requested to access the record?

Erland Olsson
Specialist nurse
Sofrosyne - Better care every day