Colombia: Requirements and procedures for obtaining a medical report within Colombia as well as from abroad; whether medical reports can be obtained through a proxy; if so, requirements and procedures; whether there is a national standard format for medical reports issued by all hospitals in the country, and the information contained therein; whether doctors have an obligation to report serious or crime-related injuries
|Publisher||Canada: Immigration and Refugee Board of Canada|
|Publication Date||4 January 2012|
|Citation / Document Symbol||COL103881.E|
|Related Document||Colombie : information sur les exigences et la marche à suivre pour obtenir un rapport médical en Colombie ainsi que depuis l'étranger; information indiquant si un rapport médical peut être obtenu par procuration; le cas échéant, information sur les exigences et la marche à suivre; information indiquant si une forme type de rapport est utilisée par tous les hôpitaux au pays et information sur les renseignements qu'il contient; information indiquant si les médecins sont tenus de signaler les blessures graves ou liées à un acte criminel|
|Cite as||Canada: Immigration and Refugee Board of Canada, Colombia: Requirements and procedures for obtaining a medical report within Colombia as well as from abroad; whether medical reports can be obtained through a proxy; if so, requirements and procedures; whether there is a national standard format for medical reports issued by all hospitals in the country, and the information contained therein; whether doctors have an obligation to report serious or crime-related injuries, 4 January 2012, COL103881.E, available at: http://www.refworld.org/docid/50b761962.html [accessed 28 December 2014]|
|Disclaimer||This is not a UNHCR publication. UNHCR is not responsible for, nor does it necessarily endorse, its content. Any views expressed are solely those of the author or publisher and do not necessarily reflect those of UNHCR, the United Nations or its Member States.|
Access to medical records (historias clínicas) in Colombia is governed by Resolution No. 1995 of 1999 (Resolución No. 1995 de 1999), which established the regulations for managing clinical records and stipulates the following:
ARTICLE 14 - Access to Clinical Records
Under the terms set forth under the Act, the following persons may have access to information found in clinical records:
- The user.
- Health professionals.
- Judicial and health authorities, in the cases stated in the Act.
- Other persons, as stated in the Act.
PARAGRAPH. In all cases, access to clinical records is understood to mean: access that is solely and exclusively for relevant purposes in accordance with the Act. The legal obligation to withhold information shall be maintained in all cases. (Colombia 1999)
The 1999 regulations were modified in 2005 (ibid. 2005). Article 15 of Resolution No. 1715 of 2005 provides the following timeframes for retaining medical records:
ARTICLE 15 - Period for Keeping Records
Clinical records must be kept for a minimum period of ten (10) years after the most recent date of medical care: a minimum of three (3) years in the files of the health service provider, and a minimum of seven (7) years in the central archives.
After this period, the clinical records may be destroyed. (Colombia 2005)
Procedures to Obtain Medical Records
Among the health service facilities researched, the procedures to obtain medical records vary; for example, at the Hospital La Victoria, in Bogota, as well as at the Compensar health promotion agency (Entidad Promotora de Salud, EPS) (Compensar EPS n.d.b), which has primary care network of 18 health service units throughout Bogota (ibid. n.d.c), a citizen must go to the facility in person, present his or her national identity document (cédula de ciudadanía) and fill out an application form (Hospital La Victoria 2007, 14; Compensar EPS n.d.a). At the Hospital Pablo Tobón Uribe, in Medellin, one can go in person or make the request by e-mail (n.d.). At the Clínica Medellín, one can go in person or make the request by mail (18 Oct. 2011).
Two of the health service facilities indicated that if the patient is a minor, the medical record will be given only to a parent or legal representative who provides documentary evidence of the relationship, the parent or legal representative's national identity document, the signed request (Hospital Pablo Tobón Uribe n.d.; Hospital La Victoria 2007, 14-15), and the minor's identity document (Hospital Pablo Tobón Uribe n.d.).
Procedures for obtaining medical records by a proxy also varied among the health service facilities that were researched (Hospital La Victoria 2007; Clínica Medellín 18 Oct. 2011; Compensar EPS n.d.a; Hospital Pablo Tobón Uribe n.d.). At three of the facilities, medical records can be obtained by a proxy as long as the proxy presents his or her national identity document and a letter of authorization from, and a copy of the national identity document of, the patient (ibid.; Clínica Medellín 18 Oct. 2011; Compensar EPS n.d.a). None of these institutions require the letter of authorization to be notarized (ibid.; Clínica Medellín 18 Oct. 2011; Hospital Pablo Tobón Uribe n.d.).
In contrast, the Chief of Medical Records and Statistics (Registros Médicos y Estadística) at the Hospital Universitario San Vicente Fundación, which is based in Medellin, indicated in correspondence with the Research Directorate that the hospital accepts requests through third parties as long as the third party provides a notarized letter from the patient (4 Nov. 2011). In correspondence with the Research Directorate, a lawyer at the Hospital Universitario de la Fundación Santa Fe de Bogotá, indicated that a patient may access a medical record through a proxy as long as the proxy provides a written request with the patient's fingerprint on the letter and a copy of the patient's identity document (Fundación Santa Fe de Bogota 17 Nov. 2011).
Some of the health service facilities that were researched charge a fee for medical records (Hospital Universitario San Vicente Fundación 4 Nov. 2011; Hospital Pablo Tobón Uribe n.d.; Compensar EPS n.d.a).
Among the health service facilities researched, waiting times vary from institution to institution; for example, Compensar EPS indicates that a patient can get a copy of a medical record three days after it has been requested (ibid.); the Hospital La Victoria requires 48 hours for the copy of the medical record to be ready for pick-up by the patient (2007, 15); and the Hospital Pablo Tobón Uribe gives a paper copy of the medical record the same day, or a compact disc (CD) in five working days (n.d.). At the Pablo Tobón Uribe hospital, if the requested copy covers records prior to 2006, it can be ready in one day, but it is not available in CD format (ibid.).
Applications by Correspondence
Among the health service facilities researched, the procedures to obtain medical records by correspondence varied from institution to institution; for example, the Hospital Pablo Tobón Uribe receives requests by e-mail, requiring scanned copies of the national identity document and a letter of authorization as an attachment (n.d.). The hospital sends the medical record in CD format within 15 working days of receipt of the application (Hospital Pablo Tobón Uribe n.d.). The Hospital Universitario San Vicente Fundación also receives applications by e-mail, or by fax, as long as the person attaches a scanned copy of a notarized letter of request (Hospital Universitario San Vicente Fundación 4 Nov. 2011). The hospital sends by e-mail or fax a summary of the medical record but not the complete medical record (ibid.). In a telephone interview with the Research Directorate, the Chief of Clinical and Administrative Records (Registros Clínicos y Administrativos) at the Clínica Medellín indicated that the institution may send a copy of the medical record by mail as long as the patient provides a letter of request, a copy of the identity document and a pre-paid, self-addressed envelope (Clínica Medellín 18 Oct. 2011).
The lawyer at the Fundación Santa Fe de Bogotá indicated that a patient in another country wishing to obtain a medical record must contact the foundation to provide a bank account number to cover the fee for the copy and postal expenses (Fundación Santa Fe de Bogotá 17 Nov. 2011).
Components of the Medical Record
Resolution No. 1995 of 1999 stipulates the following with regard to the components of medical records:
ARTICLE 9 - User Identification
Establishing rules for management of the medical history. The minimum contents of this component are: personal user identification data, full surnames and given names, marital status, identity document, date of birth, age, sex, occupation, home and mailing address and telephone number, name and telephone number of accompanying person; name, telephone number and relationship of the person responsible for the user, if applicable; insurer and type of membership.
ARTICLE 10 - Specific Records
A specific record is the document containing information and reports on a specific type of care. The health service provider must select the specific records that correspond to the nature of the services provided and must enter the information on the care provided to the user.
The minimum information that the specific record must contain with regard to the care provided to the user is governed by Resolution 2546 (July 2, 1998) and any regulations amending or supplementing the same, and by generally accepted practices in the health care field.
PARAGRAPH ONE. Each institution may determine which additional information on clinical history, if any, is necessary for adequate patient care.
PARAGRAPH TWO. All health services providers must, by means of the respective act, make use of specific records in keeping with the services provided by their institution, as well as the contents of same, which include, in addition to the minimum contents, such contents as are required for proper care of the patient. The service provider may use formats and recording media suited to its needs, without prejudice to compliance with the instructions issued by the competent authorities.
ARTICLE 11 - Attachments
All documents that serve as legal, technical, scientific and/or administrative support for the actions carried out with respect to the user in the treatment process, such as: authorizations for surgery (informed consent), procedures, authorization for autopsy, statement of voluntary retirement and other documents deemed relevant by the provider institutions.
PARAGRAPH ONE. Reports on paraclinical examinations may be turned over to the patient after the results are recorded in the medical history, in the specific record of paraclinical examinations that the service provider is required to establish to that end.
PARAGRAPH TWO. As of the date of issue of this resolution, in the case of diagnostic images, image interpretation reports must also be recorded in the specific record of paraclinical examinations, and diagnostic images may be turned over to the patient, explaining to him/her the importance of their preservation for future analysis. A note concerning such action must be entered in the medical history together with the patient's signature. ...
Paragraph Four. The service provider shall be responsible for such images in all cases in which a note has not been entered in the medical history to the effect that they were turned over. When the user has signed to that effect, the latter shall be responsible for preservation thereof. (Colombia 1999)
Medical reports from the National Institute of Legal Medicine and Forensic Sciences
The National Institute of Legal Medicine and Forensic Sciences (Instituto Nacional de Medicina Legal y Ciencias Forenses, INMLCF) is the state institution responsible for the administration of medico-legal assessments requested by [translation] "attorneys, judges, the Judicial Police, the Office of the Ombudsperson and other competent authorities in the country" (Colombia 22 Nov. 2011), which are involved with a judicial process (ibid. n.d.a). As such, the INMLCF provides "scientific and technical support to the administration of justice" in six areas: autopsies, search for missing persons, psychiatric evaluations, general medical examinations, genetic investigations, and the return of bodies (ibid. n.d.b) to authorized persons (ibid. n.d.c).
In correspondence with the Research Directorate, the Chief of the Legal Office (Oficina Jurídica) at the INMLCF stated that persons interested in obtaining copies of medical reports produced by that institution must have the authorization of a [translation] "competent authority" (Colombia 22 Nov. 2011). A lawyer at the Legal Office indicated in a telephone interview by the Research Directorate that "competent authority" refers to the judge assigned to the case (ibid. 15 Dec. 2011). In addition, the Legal Office representatives explained that the interested person must obtain such authorization through a lawyer or the prosecutor assigned to the case (ibid. 12 Dec. 2011; ibid. 22 Nov. 2011).
For requests made in cities other than the one in which the report was made, the person may send the authorized request to the nearest branch of the INMLCF (ibid.). Requests through proxies can be made either within Colombia or from abroad as long as the proxy has a notarized authorization from the interested person and authorization from the "competent authority" (ibid.).
With regard to the format that the INMLCF uses for its reports, the Legal Office chief indicated that it is standardized for all its branches, and that the information fields contained in the reports depend on the type of crime (ibid.).
According to the records chief at the Clínica Medellín, hospitals and health care centres are required to notify police when they have treated a person for crime-related injuries (Clínica Medellín 18 Oct. 2011). The lawyer at the Fundación Santa Fe de Bogotá indicated the following:
In Colombia, any person that witnesses criminal conduct has the legal obligation to report it to the authorities. Therefore, if the hospital learns that the injuries of a person are presumably from a violent action that involves criminality, the Hospital has the obligation to report it. (Fundación Santa Fe de Bogotá 17 Nov. 2011)
This Response was prepared after researching publicly accessible information currently available to the Research Directorate within time constraints. This Response is not, and does not purport to be, conclusive as to the merit of any particular claim for refugee protection. Please find below the list of sources consulted in researching this Information Request.
Clínica Medellín. 18 October 2011. Telephone interview with the Chief, Registros Clínicos y Administrativos.
Colombia. 15 December 2011. Instituto Nacional de Medicina Legal y Ciencias Forenses. Telephone interview with a lawyer.
_____. 12 December 2011. Instituto Nacional de Medicina Legal y Ciencias Forenses. Telephone interview with a lawyer.
_____. 22 November 2011. Instituto Nacional de Medicina Legal y Ciencias Forenses. Correspondence from the Chief, Oficina Juridica, to the Research Directorate.
_____. 2005. Resolución No. 1715 de 2005. Translated by the Translation Bureau, Public Works and Government Services Canada.
_____. 1999. Resolución No. 1995 de 1999. Translated by the Translation Bureau, Public Works and Government Services Canada.
_____. N.d.a. Instituto Nacional de Medicina Legal y Ciencias Forenses. "Servicios."
_____. N.d.b. Instituto Nacional de Medicina Legal y Ciencias Forenses. "Objetivos y funciones."
_____. N.d.c. Instituto Nacional de Medicina Legal y Ciencias Forenses. "Servicios - Entrega de cadáveres."
Compensar, EPS. N.d.a. "Formato para solicitud de copia de historia clínica."
_____. N.d.b. "Marco legal."
_____. N.d.c. "Modelo de salud compensar para vivir más cerca de nuestros afiliados."
Fundación Santa Fe de Bogotá. 17 November 2011. Hospital Universitario. Correspondence from a lawyer to the Research Directorate.
Hospital La Victoria. 2007. Manual de manejo y diligenciamiento de historia clínica.
Hospital Pablo Tobón Uribe. N.d. "Requisitos para reclamar la historia clínica."
Hospital Universitario San Vicente Fundación. 4 November 2011. Correspondence from the Chief, Registros Médicos y Estadistica, to the Research Directorate.
Additional Sources Consulted
Oral sources: Attempts to contact representatives of Clínica CES, Clínica SOMA, Fiscalía General de la Nación and Policía Nacional de Colombia were unsuccessful.
Internet sites, including: Amnesty International, El Colombiano, El Espectador, Factiva, Fiscalía General de la Nación, Freedom House, Human Rights Watch, Ministerio de la Protección Social, El Mundo, Organization of American States, Policía Nacional de Colombia, Semana, El Tiempo, United Nations High Commissioner for Refugees, World Health Organization.