How to obtain your medical history and copies of documents from a clinic

Your legal rights: access, copies and corrections

Article 17 of the Law of Georgia on Patient Rights sets out three things about medical records. First, patients may see their own medical records. Second, they may request a copy of any part of the record, not only the sheet the clinic hands over on discharge. Third, such a request is submitted to the medical facility in writing. A relative and a legal representative enjoy the same right with the patient's consent, and for a minor patient, a parent or other legal representative.

An important detail: you receive a copy. The original medical file stays at the clinic and is kept for the prescribed period, so "taking your history" in practice means receiving a certified copy or extract. If you notice a mistake in the record, such as a wrong date or an omitted allergy, request a correction or addition in writing: the old entry is not deleted, and the new one is recorded next to it.

This article of the law does not give a specific response time in days. So it is advisable to state a reasonable deadline in your letter yourself, together with the reason you need the document promptly, for example the date of a consultation at a clinic abroad. If the clinic does not reply or refuses, the steps for a complaint are described on the patient rights page.

Which records exist and which do you need?

"Give me my history" is a vague request for the reception desk. A single hospital stay produces several different documents, and each is needed by a different recipient. The table helps you list in your request exactly what serves your purpose.

Form 100 is not on this list, because it is not a copy of an existing record but a certificate newly drawn up by a doctor; how to get one is explained in the Form 100 guide.

Structure of the request letter: seven blocks

The letter does not need a special form, but it should contain seven blocks. Each answers a question that the clinic's registry or archive would otherwise ask you by phone, delaying the process by several days.

1. Addressee

   The clinic's full legal name and the name of the director or medical director. If the clinic has several branches, state which one treated you.

2. Applicant

   First name, surname, personal ID number, address and phone number. If you are not the patient, state here on whose behalf and in what capacity you are making the request.

3. Basis

   For the patient, it is enough to state that they are requesting their own record. Anyone else attaches the patient's written consent or a power of attorney; a parent, the child's birth certificate; a supporter, the court decision.

4. Period and department

   The dates of the hospital stay or visits, the department and, if you know it, the case history number. This one line significantly shortens the search in the archive.

5. List of documents

   A numbered list: discharge summary, operation notes, laboratory test results, imaging reports, images in DICOM format. Add the word "all" at the end of the list, not instead of it.

6. Form of delivery

   On paper with the clinic's stamp and the signature of an authorised person, electronically via a secure link, images on a disc. If the document is going abroad, ask for a stamped paper copy, because the translation and certification will be based on it.

7. Deadline, date, signature

   State by what date you need the documents and why, sign the letter and attach a copy of your ID card.

Take the letter in two copies: one stays with the registry, and the other is marked with the registration number and date. If you send it by email, use the clinic's official address and keep the confirmation that it was sent.

A deceased relative's records: who can get them and on what basis?

The clinic's duty of confidentiality does not end with the patient's death: under Article 27 of the law, information is protected both during the patient's lifetime and after death. At the same time, a power of attorney given during the patient's lifetime ends with their death, so the family needs a different basis to obtain the record.

In practice, a clinic issues the record to a close relative or heir who proves their basis with documents. As a rule, the request is accompanied by:

• the death certificate or an extract from the civil registry;
• a document proving the relationship: a birth or marriage certificate, several together if needed, so that the family link is shown in full;
• a certificate of inheritance or a notary's certificate on the inheritance case, if the clinic asks for proof of inheritance;
• a statement of purpose: an insurance claim, inheritance, a medical dispute or the family history of hereditary diseases.

The law defines a relative as a person who has priority under the order established by legislation. So when several family members request the same record, or the clinic considers the basis insufficient, the matter is decided on the specific facts. If the case concerns compensation for harm or a dispute about the quality of treatment, requesting the record is often the first step in a medical dispute, and it is better to word the letter with a lawyer.

The clinic has closed or changed its name: where to look for the archive?

A clinic's closure does not automatically mean the record has disappeared. Under Order No. 01-35/n of the Minister of Health of 2019, medical records are kept at the facility for the period set by the departmental schedule, and records intended for the National Archival Fund are transferred, in the manner established by law, to the National Archives or a private archive. It is best to search in this order:

1. Legal successor. Georgian clinics often merge, are sold or change their names. An extract from the Public Registry shows whether the legal entity was reorganised and who its legal successor is; the records usually pass to the successor.
2. New owner of the building. If another clinic operates at the same address, ask whether it took over the old archive; sometimes the records physically remain on site.
3. Archive. If the legal entity has been liquidated, contact the National Archives and ask which archive its documents were transferred to.
4. Alternative sources. Some of the same information is kept elsewhere too: in the family doctor's file, at the laboratory, in the insurance company's file, in the electronic record or in your own personal folder.

If the record cannot be found anywhere, ask for a written reply stating that it does not exist: a clinic or insurer abroad will often accept such a reply as an explanation for a missing document. Searching for old records takes time and sometimes involves several authorities; if you cannot manage it yourself, the certificates and records retrieval service does this work on your behalf.

The electronic record: what you can see online and what it cannot replace

Since 2019, Georgia has had an electronic health records system to which inpatient and outpatient facilities must upload patient data. The minister's order regulating the system gives patients access to their own page, by logging in through the Ministry of Health's citizen portal or my.gov.ge. Under the same order, patients may ask for a particular visit or hospital stay to be hidden from other users or, conversely, shared.

The electronic record is a good starting point: it shows exactly at which facility and when you were treated, which makes your request for a paper copy more precise. However, bear in mind three limitations:

• a printout from the portal carries no clinic stamp or doctor's signature, so an embassy, a foreign insurer or a court will, as a rule, not accept it as an official document;
• the system often shows summary data rather than every full document, for example the operation notes;
• radiology images and histology material are kept separately, and you obtain them from the clinic or laboratory.

You have the copy: what to check and what to do next

As soon as you receive it, before you leave the clinic, check three things: your name, surname and personal ID number match your ID on every page; every document you listed is there; the stamp and signature are legible. A gap is easiest to fix the same day, while a week later it requires a new request.

The next step depends on the recipient. For another Georgian doctor, the copy can be used as it is. For a clinic abroad, it is translated: the terms for translating discharge summaries and reports are on the medical translation page, and you can work out the price in advance with the translation calculator. If you are requesting the record for a second opinion, see what material a doctor abroad needs; if treatment abroad is planned, all the necessary documents are gathered, stage by stage, in the full document checklist.

Frequently asked questions about medical records