How to get a copy of your observation chart (medical record)

The hospital or clinic is required to give you, on written request, a copy of your medical record — including the observation chart and the results of investigations. You have two legal grounds that reinforce each other: the right of access to your personal medical data (Art. 24 of Law no. 46/2003) and the right of access provided by GDPR (EU Regulation 2016/679 and Law no. 190/2018). The first copy is, as a rule, free, and the response deadline is at most one month.

Below is how you request the copy, how much it costs, how long it takes, and what to do if you are refused.

What you can request

From your medical record you can request copies of:

• the general clinical observation chart (FOCG) — the central document of the hospital stay;
• the results of the lab tests and investigations;
• imaging (MRI, CT, ultrasound, X-rays) — usually on CD/DVD;
• the discharge note and the medical letter;
• the operative report, if you were operated on.

The legal basis

You have two rights that complement each other:

• Art. 24 of Law no. 46/2003: “The patient has access to their personal medical data.”
• The GDPR right of access (Art. 15 of EU Regulation 2016/679): you can obtain confirmation that your data is being processed and a copy of it. In Romania, GDPR is supplemented by Law no. 190/2018.

The implementing rules of Law 46/2003 (Order of the Ministry of Health no. 1410/2016) detail the provider’s obligation to make your medical information available on request.

How to request it, step by step

1. Write a request addressed to the management of the unit (hospital/clinic). Mention: your name, personal numeric code (CNP), the hospitalization period and the ward, as well as which documents you want (copy of the observation chart, results, etc.).
2. Submit the request at the registry office (registratură) and ask for the registration number. You can also send it by email or post, with acknowledgment of receipt.
3. For imaging, explicitly ask for the CD/DVD with the images, not just the written report.
4. Collect the copies when notified, or receive them through the channel indicated in the request.

You do not need to justify why you are requesting the copy — it is your data.

How much it costs

The first copy of your data is, in principle, free — this is what GDPR provides (Art. 12). For additional copies or for large volumes, the unit may charge a reasonable fee, based on the reproduction cost (copying, printing, CD media). Fees differ from one unit to another — ask at the registry office (registratură) or check the hospital’s website.

How long until you get the copy

GDPR provides for a response without undue delay and within at most one month of receiving the request (Art. 12(3)). The deadline can be extended by a further two months for complex or numerous requests, in which case the unit must notify you. In practice, many hospitals issue the copies faster — but if you need it urgently (for example for a second opinion), mention that in the request.

Tips to get the copy faster

• Request the copies right at discharge, when the record is fresh and the staff know you — it is simpler than coming back months later.
• Be precise in the request: exactly which document, which hospital stay, and which period. A vague request is harder to process.
• Also request the electronic format if it is useful to you — some units can issue scanned documents in addition to the paper copies.
• Keep the original of the request with the registration number; it will be useful if you later need to complain about a delay.
• If you are going for a second opinion, request the copies in good time, so the new doctor has all the data at the first consultation.

What to do if you are refused

If the unit refuses or drags its feet:

• ask for the refusal in writing and with reasons;
• report it to ANSPDCP (the National Supervisory Authority for Personal Data Processing, dataprotection.ro) — it is the authority for the right of access to data;
• you can also report it to the Public Health Directorate (DSP) for the medical unit;
• keep the evidence (the registered request, the correspondence).

Special cases

• Minor children: the request is made by the parent or legal representative.
• Relatives / deceased persons: confidentiality is maintained even after death (Art. 21). Access is limited and, as a rule, possible for heirs or legal representatives, under the conditions of the law — ask at the unit what documents are needed.
• Through an authorized person: you can authorize someone else to collect the copies through a power of attorney.

Key takeaways

• You have the right to a copy of your medical record — dual basis: Law 46/2003 and GDPR.
• You request it in writing, with a registration number; you do not have to justify it.
• The first copy is, as a rule, free; the deadline is up to one month.
• A refusal is challenged at ANSPDCP and/or at the DSP.

Sources

• Law no. 46/2003 on patient rights (Art. 24 — access to personal medical data)
• Order of the Ministry of Health no. 1410/2016 — Implementing rules for the Patient Rights Law no. 46/2003
• Regulation (EU) 2016/679 (GDPR), Art. 12 and 15 — the right of access and the copy of the data
• Law no. 190/2018 on measures implementing Regulation (EU) 2016/679
• ANSPDCP — dataprotection.ro