Peru: Whether a medical report can be obtained by a person in Peru or abroad, or by a third party; the procedure to be followed, including whether there is standard report format at the national level; whether doctors are obliged to report to the authorities serious injuries or injuries sustained as a result of a crime

In a telephone interview with the Research Directorate, an assistant director of the General Secretariat of Health Insurance (Secretaría general del Seguro social de salud, EsSalud) in Peru indicated that the health system in Peru is divided into two networks: one for health-insurance hospitals and another for hospitals under the Department of Health (Peru 8 Feb. 2012). She stated that health-insurance hospitals serve employees of companies that have health insurance, while the hospitals under the Department of Health serve individuals with low incomes (ibid.). She added that there are also health centres or private clinics accessible to wealthier patients (ibid.).

The Assistant Director stated that it is indeed possible for a person in Peru or abroad to obtain a copy of a medical report, and that it is a right defined in Peru's General Health Act No. 26842 (Ley General de Salud nº 26842) (ibid.).

According to Article 15 of Peru's General Health Act No. 26842,

[translation]

Every health service user is entitled to

i) a discharge record at the end of their stay at a health facility and, if requested, a copy of their patient case summary report and health record (Peru 1997, Art. 15(i)).

According to the Technical Standards for Managing Medical Files, approved by the Department of Health on 28 June 2006, the hospitalization report [translation] "must be written by the attending physician when the patient leaves the health-care institution" and that document must contain the following information:

[translation]

• the date and time of admission
• the ward and bed number
• the admitting diagnosis
• a summary of the current illness, the physical examination, secondary examinations, the course of the illness, and the treatment
• the therapeutic and diagnostic procedures performed ...
• complications
• the date and time the patient was discharged and the number of days he or she was hospitalized
• the conditions of release of the patient
• the principal and secondary diagnosis ...
• information about the death (if applicable): whether an autopsy will be conducted and the causes of death
• first and last names, signature, the seal and licence number of the attending physician while the patient was hospitalized (Peru 2007, 20).

The medical file is divided into three parts: patient identification, the medical attendance record and additional information (ibid., 14). The first part contains information regarding the patient's identity, the medical file number, and the particulars of the health-care institution consulted, the second part contains the record of the health care given to the patient, and the third part provides the results of additional examinations and legal, technical, scientific or administrative documents (ibid.). The Assistant Director did not indicate whether, in practice, all medical files respect this format.

With regard to the medicare system in Peru, the Assistant Director stated that, to obtain a copy of the medical consultation, the patient must sent a letter to the director of the medicare system, indicating his or her national identification number and the reason for the request (Peru 8 Feb. 2012). She indicated that a third party can also make such a request, on the condition that that person has a signed and notarized authorization from the patient (ibid.). In the case of a minor, the parents or legal guardian must make the request on behalf of the child (ibid.).

She also noted that, in general, it is easy to obtain a copy of a medical consultation, but she was unable to specify how long it took because, according to her, that can vary depending on the organization and the location (ibid.). Furthermore, she stated that there are charges of 15 soles (PEN) [C$5.56 (XE 9 Feb. 2012a)] for administrative fees and 0.15 PEN [C$0.05 (ibid. 2012b)] for each photocopy made (Peru 8 Feb. 2012).

Information about obtaining a medical report from the Department of Health's network or from health centres or private clinics in the country could not be found among the sources consulted by the Research Directorate.

With regard to whether doctors are obliged to notify the authorities of serious injuries or injuries sustained as a result of a crime, the Assistant Director stated that stabbing and gunshot wounds, for example, must be reported to the police (ibid.). Articles 25 and 30 of the General Health Act of Peru stipulate the following:

[translation]

Article 25

All information regarding medical procedures being performed is designated "protected." Health professionals, technicians and assistants who provide or disclose, by any means, information regarding the medical procedure in which they were involved or to which they were privy, are criminally or civilly liable, as applicable, notwithstanding any penalties that may be applicable under the Professional Code of Ethics.

The following medical procedures are exempt from this:

...

g) when continuity of the patient's care requires it. Information related to the injury/harm diagnosis, in the cases referred to in Article 30 of this Act, must be reported to police/attorney general authorities upon request (Peru 1997, Art. 25).

Article 30

Physicians who provide medical attention to persons wounded or injured by blade, bullet, traffic accident or any other kind of violence punishable by law, or where there are signs of criminal abortion, must report that information to the appropriate authorities (ibid., Art. 30).

The Medical File Management Technical Standards contain samples of the various forms used in providing outpatient care to a child, an adolescent, an adult or a senior citizen, or during a family visit (Peru 2007, 38-63). These forms are also accessible on the Department of Health's website (Peru 2007).

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

Peru. 8 February 2012. Seguro Social de Salud. Telephone interview with an assistant director.

_____. 2007. Ministerio de Salud. Norma técnica de salud para la gestión de la historia clínica. [Accessed 19 Jan. 2012]

_____. 1997. Ley General de Salud. Ley nº 26842. Articles 15, 25 and 30 translated by the Translation Bureau, Public Works and Government Services Canada. [Accessed 7 Feb. 2012]

XE. 9 February 2012a. "Résultats du convertisseur universel de devises." [Accessed 9 Feb. 2012]

_____. 9 February 2012b. "Résultats du convertisseur universel de devises." [Accessed 9 Feb. 2012]

Additional Sources Consulted

Oral sources: Attempts to contact representatives of the following organizations were unsuccessful: Federación Médica Peruana, Ministerio de Salud del Perú, Seguridad Social del Perú. Representatives of the World Health Organization in Peru could not provide any information.

Internet sites, including: Federación Médica Peruana, Ministerio de Salud del Perú, Seguridad Social del Perú, World Health Organization in Peru.