Last Updated: Tuesday, 22 July 2014, 14:00 GMT

Venezuela: Whether a medical report can be obtained by a person who is in Venezuela or outside the country or by a third party; the procedure to be followed, including whether there is a national standard format; whether doctors are required to report to the authorities serious injuries or injuries inflicted during the commission of a crime

Publisher Canada: Immigration and Refugee Board of Canada
Publication Date 17 May 2012
Citation / Document Symbol VEN103951.FE
Related Document Venezuela : information indiquant si un rapport médical peut être obtenu par une personne qui se trouve au Venezuela ou à l'extérieur du pays ou par une tierce personne; information indiquant la marche à suivre, y compris s'il existe un format standard au niveau national; information indiquant si les médecins sont tenus de signaler aux autorités les blessures graves ou infligées lors d'un crime
Cite as Canada: Immigration and Refugee Board of Canada, Venezuela: Whether a medical report can be obtained by a person who is in Venezuela or outside the country or by a third party; the procedure to be followed, including whether there is a national standard format; whether doctors are required to report to the authorities serious injuries or injuries inflicted during the commission of a crime, 17 May 2012, VEN103951.FE, available at: http://www.refworld.org/docid/51346fb42.html [accessed 22 July 2014]
DisclaimerThis 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.

1. Patient Rights

According to Article 69 of Venezuela's Organic Law on Health (Ley Orgánica de Salud),

[Translation]

All patients shall have the following rights:

...

A medical record, in which the attending physician or any other person authorized to act in his/her place, enters and certifies all relevant information on the patient's illness, the reason for the consultation, the patient's medical history, the history of the patient's current illness, the primary and secondary diagnoses, the treatments and the clinical progression, as well as the status of the patient's health at the time of discharge, the prescribed treatment and follow-up consultations. Where the patient is required to continue or requests treatment at another health care facility, the patient is given a written and certified summary of his/her medical record.

Confidentiality of patient records. (Venezuela 1998)

2. Procedures

During a telephone interview with the Research Directorate, a lawyer working at a private firm specializing in criminal and human rights law said that because there is no central organization responsible for issuing medical reports in Venezuela, the person concerned must go in person to the medical centre where he or she was treated to get a copy of the report (Lawyer 1 May 2012). In addition, he said that the person can also designate another person or a lawyer to get a copy of the report; the designated person must have a letter of authorization and a copy of an identity document belonging to the patient (ibid.). The letter of authorization does not have to be notarized (ibid.). If the person lives in another country, he or she should preferably designate another person or a lawyer in Venezuela to get the copy of the report, because it is [translation] "unlikely" that he or she can get the copy by presenting a written request (ibid.). Venezuela, the person concerned must go in person to the medical centre where he or she was treated to get a copy of the report (Lawyer 1 May 2012). In addition, he said that the person can also designate another person or a lawyer to get a copy of the report; the designated person must have a letter of authorization and a copy of an identity document belonging to the patient (ibid.). The letter of authorization does not have to be notarized (ibid.). If the person lives in another country, he or she should preferably designate another person or a lawyer in Venezuela to get the copy of the report, because it is [translation] "unlikely" that he or she can get the copy by presenting a written request (ibid.). Information corroborating the information provided by the lawyer could not be found among the sources consulted by the Research Directorate.

3. Santa Sofía Clinic

In a telephone conversation with the Research Directorate, a doctor at the Santa Sofía Clinic (Clínica Santa Sofía), a private medical clinic in Caracas, stated that a person who has been hospitalized or operated on at the Santa Sofía Clinic can get a copy of the medical report (Clínica Santa Sofía, 5 Jan. 2012). The doctor explained that if the person has consulted a doctor at an outpatient clinic, the Santa Sofía Clinic cannot provide a copy of the medical report (ibid.).

To get a copy of a medical consultation report, the patient must send a letter to the management of the Santa Sofía Clinic, stating his or her name, identity card (cédula de identidad) number, the date of the consultation, the information being sought and the reason for the request (ibid.). There is no charge, according to the doctor (ibid.). The doctor also stated that the time it takes to get a copy of the medical report can vary, from a few days if the consultation took place within the previous 24 to 48 hours, or 7 to 10 days if the consultation took place more than 48 hours earlier (ibid.). He also indicated that a patient could contact his or her attending physician directly and may be able to get a response more quickly (ibid.). However, he could not confirm the response time or the cost of such a request (ibid.). He added that the procedure is the same for a person located outside the country (ibid.).

If someone cannot make the request in person, he or she can ask their spouse to make the request on their behalf (ibid.). The spouse will have to provide the management of the Santa Sofía Clinic with a notarized authorization when requesting a copy of a medical report (ibid.). For minors, parents or legal representatives are responsible for submitting the request on the child's behalf (ibid.). According to the doctor, the clinic does not receive frequent requests for medical reports (ibid.).

4. Institute of Clinical and Urology Services

During a telephone conversation with the Research Directorate, a receptionist at the Tamanaco Institute of Clinical and Urology Services (Instituto de Clínicas y Urología Tamanaco), which is located in Caracas, stated that a patient has to contact their attending physician directly to get a copy of a medical report (Instituto de Clínicas y Urología Tamanaco, 5 Jan. 2012). She said that the response time varies and that [translation] "it all depends on the doctor" (ibid.). Additional information on the medical reports of the Instituto de Clínicas y Urología Tamanaco could not be found among the sources consulted by the Research Directorate.

5. Format of the Medical Report

The doctor at the Santa Sofía Clinic explained that the medical record is in a standard format that is used nationally (Clínica Santa Sofía, 5 Jan. 2012), and the main information included is the following: the patient's name, address and telephone number, medical history, clinical examinations, the reason for the consultation, a description of the consultation, and the diagnosis (ibid.). Corroborating information or information on the format of the medical report could not be found among the sources consulted by the Research Directorate.

6. Requirement to Report Serious Injuries or Injuries Inflicted during the Commission of a Crime

Concerning whether or not doctors are required to report serious injuries or injuries inflicted during the commission of a crime to the authorities, the doctor at the Santa Sofía Clinic stated that when a person is admitted to emergency, the doctor is required to make a report to the Police Forensic Unit (Policía Cientifíca), which is responsible for investigating acts of violence and taking victim statements (Clínica Santa Sofía, 5 Jan. 2012). For other cases, the doctor stated that [translation] "it is up to the doctor" and that [translation] "the doctor and the patient can discuss the matter together" (ibid.). The lawyer also said that doctors are required to report injuries resulting from criminal acts to the police, but he pointed out that [translation] "this does not mean that doctors always do so" (Lawyer, 1 May 2012).

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.

References

Clínica Santa Sofía. 5 January 2012. Telephone interview with a doctor.

Instituto de Clínicas y Urología Tamanaco. 5 January 2012. Telephone interview with a receptionist.

Lawyer, Caracas, Venezuela. May 1, 2012. Telephone interview.

Venezuela. 1998. Ley Orgánica de Salud. Article 69 translated by the Translation Bureau, Public Works and Government Services Canada. [Accessed 14 February 2012]

Additional Sources Consulted

Oral sources: Attempts to reach representatives of the following organizations were unsuccessful: Centro Médico Docente la Trinidad; Clínica Acosta Ortiz; Federación Médica Venezolana; Hospital Central Rafael Zamora Arévalo; Hospital San Juan de Dios; Hospital Universitario de Maracaibo; Instituto Nacional de los Servicios Sociales; Instituto Venezolano de los Seguros Sociales; Venezuela — Ministerio del Poder Popular para la Salud, Policlínica Metropolitana. Representatives of the following organizations were unable to provide information within the time constraints of this response: Hospital Universitario de Caracas; United Nations — World Health Organization in Venezuela; Venezuela — Embassy of the Bolivarian Republic of Venezuela in Ottawa.

Internet sites, including: Academia Nacional de Medicina; Centro Médico Docente la Trinidad; Clínica Acosta Ortiz; Clínica Santa Sofía; Hospital Oncológico Luis Razetti; Hospital San Juan de Dios; Hospital Universitario de Caracas; Hospital Universitario de Maracaibo; Instituto de Clínicas y Urología Tamanaco; Venezuela — Ministerio del Poder Popular para la Salud.

Copyright notice: This document is published with the permission of the copyright holder and producer Immigration and Refugee Board of Canada (IRB). The original version of this document may be found on the offical website of the IRB at http://www.irb-cisr.gc.ca/en/. Documents earlier than 2003 may be found only on Refworld.

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