A patient may examine the health records concerning them and obtain a copy. This right cannot be reduced to the discharge summary or to the information displayed on the e-Nabız screen. Documents such as operation, anesthesia, medication, follow-up and consent records should be requested separately, according to the scope of the specific treatment. A family relationship does not always grant access; identity, representation and the protection of third parties' data are assessed together. [1] [2]
In a medical malpractice claim, obtaining the file early makes it easier to establish the sequence of events and to identify which information is missing. A lawsuit does not have to be filed beforehand in order to request records.
Does the patient file consist only of the discharge summary?
The discharge summary (epikriz) is a summary of the health process. It does not contain the details of each procedure or minute-by-minute monitoring. In a claim of medical error, reviewing only the summary document may cause important points to be overlooked.
Depending on the nature of the procedure, the following records may also be important:
- Application, examination, consultation and preliminary assessment records.
- Information forms and signed consent forms, the contract and the surgical plan.
- Operation notes, anesthesia assessment and monitoring charts.
- Physician orders, medication administration records and nurse observation records.
- Laboratory, pathology and imaging reports and, where necessary, the original image files.
- Intensive care, referral, discharge and follow-up records.
- Identifying information for the implant, product or kit used.
This list does not mean that every file will contain all of these documents. The request should be made specific to the health care received. Because a document may be kept under a different name in the institution, the request may specify not only the heading but also the content of the record sought.
Who may request the records?
Article 16 of the Patients' Rights Regulation (Hasta Hakları Yönetmeliği) governs the right of the patient to examine files and records and to obtain a copy, either personally or through an authorized representative or legal representative. The institution's verification of identity and authority is necessary to protect health data. However, access rights must not be rendered ineffective by excessive or unrelated conditions. [1]
To learn more about protecting health information, see our article on unauthorized sharing of patient photographs and health data.
Relatives and representatives
Being a spouse, child or sibling does not automatically grant the right to obtain the entire file of an adult patient who has the capacity to make decisions. The scope of authorization and representation must be determined. In applications made through a lawyer, the power of attorney and the authority conditions for access to health data are also examined.
In guardianship or custody situations, the scope of representation and the interest of the child or of the person under guardianship are taken into account. For access to the records of a deceased person, inheritance status and special rules on health data are assessed separately; the procedure applicable to an ordinary consent given by a living patient should not be assumed. Documents showing the specific right of access must be attached to the application. [1] [2] [3]
Where and how is the application made?
The application should be made to the relevant unit of the hospital or institution that keeps the records. Depending on the institution's structure, the patients' rights unit, the chief physician's office, the archive or the data controller's application channel may serve this function. The addressee of the application, the date on which it was received and the record number should be kept.
The application should state the patient's identity, the applicant's capacity, the date range of the treatment, the relevant unit and the documents requested. If an electronic copy is requested, the file may be requested in a readable format and delivered by a secure method. Rather than giving a third party the access password of a particular system, the institution's official delivery method should be used.
A short core request may be formulated as follows: “I request readable copies of the examination, operation, anesthesia, medication administration, nurse observation, consent and follow-up records relating to the health care provided to me on the dates indicated, and, for records that are incomplete or do not exist, a statement of the reasons.” This sentence should be expanded according to the specific file; it is not a ready-made petition that is sufficient for every application.
Within what period must a response be given?
The legal basis on which the application rests matters. Applications to a data controller under Article 13 of the Law No. 6698 on Personal Data Protection (KVKK) are concluded as soon as possible and at the latest within thirty days. Information requests to public bodies, under the Law No. 4982 on the Right to Information, have their own response and objection periods. It is not correct to apply the same period to every patient file request without reasoning. [2] [4]
Filing a request for the file does not by itself suspend the period for a malpractice compensation claim or a lawsuit. If the deadline is approaching, protecting the appropriate legal remedy should also be assessed while the records are awaited.
Why might e-Nabız records alone not be sufficient?
e-Nabız, the Turkish national electronic health record system, is an important source for patients accessing their health information. However, it should not be expected that all the detailed documents kept by the institution will appear within the same scope. The anesthesia monitoring chart, all pages of a signed consent form or the detailed nurse observation record may be requested from the institution separately.
The absence of a piece of information from the system does not by itself prove that the procedure was definitely not carried out. Conversely, the presence of a procedure code in the system does not show that the procedure was carried out in full compliance with all its conditions. Institutional records, payment records and the medical process should be assessed together.
In radiology, the report and the image itself are different things. For a second evaluation, the images may need to be obtained in an appropriate electronic format. A photograph of the screen does not always replace the original image file, which is suitable for examination.
How should the completeness of the delivered file be checked?
| Check item | Question to ask | If something is missing, request |
|---|---|---|
| Date range | Are all applications included? | Missing days and session records |
| Document integrity | Are all pages and attachments complete? | The complete signed copy and attachments |
| Legibility | Are the text, values and signature legible? | A legible copy |
| Procedural detail | Is the drug, product and the person who applied it recorded? | The relevant chart and identifying information |
| Electronic record | Is the time of creation or modification disputed? | Preservation of the history of changes and access logs, where needed |
When the file is delivered, the events between the first record and the last record should be placed in chronological order. Different times for the same event in different documents do not always amount to forgery; however, they may be a discrepancy that requires explanation. System clocks, later record entries and the reasons for corrections are examined.
If an error in a record is suspected, correction or completion may be requested under Article 17 of the Patients' Rights Regulation and the rights under the KVKK. The aim is not to remove the past record without a trace, but to ensure its accuracy and the auditability of any changes. A separate request should be made to preserve the original records that may serve as evidence. [1] [2]
Is re-evaluating an earlier diagnosis the same as deleting a record?
By the amendment of July 4, 2026, Article 13/A was added to the Regulation on Personal Health Data (Kişisel Sağlık Verileri Hakkında Yönetmelik). Whether a diagnosis made earlier reflects the person's current health status may, upon application, be subject to evaluation by a health board. A diagnosis made by a single physician is re-evaluated by a board of three physicians; a board diagnosis is re-evaluated by a full health board. The regulation provides that a report showing that the diagnosis no longer exists in the current situation is taken into account in subsequent procedures, without prejudice to the relevant special legislation. [7]
This path must be distinguished from a claim that an incorrect record was entered in the past, and from a request to delete the entire medical history. A new report does not, by itself, require that evidence concerning the circumstances of the earlier intervention be destroyed. In a malpractice review, the old record and the current evaluation should be preserved together.
What routes can be used if the institution does not provide the documents?
First, the grounds for refusal, the scope of any partial disclosure and the date on which the application was received should be determined. The presence of information relating to third parties does not in every case mean that the whole file must be withheld; the necessary separation or restriction should be assessed. On the other hand, the patient's right of access does not mean unlimited disclosure of the private information of other patients.
Depending on the concrete situation, the relevant administrative supervision and patients' rights channels, as well as the KVKK application and complaint routes, may be used. If litigation has begun, a request may be made to the court to obtain the documents. In private law proceedings, the production of documents and of records held by third parties are assessed under Articles 219–221 of the Code of Civil Procedure No. 6100 (HMK). If there is a risk that evidence may be lost or become harder to obtain, the preservation of evidence under HMK Article 400 et seq. may come into question. [5]
Not every records dispute is assumed to meet the conditions for preservation of evidence. The reason why a particular piece of evidence should be protected now must be explained. This justification may be particularly concrete for images whose retention period is about to expire, or for electronic records that can be altered.
For post-mortem records in cases of patient death in medical tourism, see our article on patient death, autopsy and transfer of the body in medical tourism. As a service page, see medical malpractice and physician error lawsuits.
Is a missing record an automatic ground for compensation?
The obligation to keep and preserve records is important for the health institution. However, the effect of a missing record must be shown in terms of which fact it prevents from being clarified and what effect it has on the assessment of liability. Not every deficiency means that all claims are accepted as true; on the other hand, it is not correct to load the consequences of a deficiency onto the patient without examination.
In the judgment of the Constitutional Court (Anayasa Mahkemesi) in Hasan Kamer, B.2018/11847, June 16, 2021, the Court examined whether an injection had been administered and whether the details of the application could not be determined from the records. The Court found a violation, because the obligation to keep and present records rests with the institution and because the judicial approach did not sufficiently assess the effect of the missing record on liability. A retrial decision does not mean that the physician was definitively held liable for all losses or that a specific amount of compensation was awarded. [6]
For the evidentiary value of records, see how to prove medical malpractice and objection to the expert and forensic medicine report in a malpractice case.
What additional records should be obtained for aesthetic procedures?
The surgical plan showing the agreed appearance, photographs taken before the procedure, drawings, messages and revision records are particularly important. They serve not only to evaluate a technical defect but also to assess the result undertaking in the contract for work (eser sözleşmesi). The date of each photograph, the conditions under which it was taken and the person to whom it belongs should be determined.
Using before-and-after photographs as evidence in a legal file is different from publishing them for promotional purposes. A patient who submits the document to a lawyer or a court does not thereby permit the institution to use the same image in advertising. Privacy protection continues during the preparation of evidence.
For disputes concerning aesthetic procedures, see our article on defective aesthetic surgery and hair transplantation compensation.
Conclusion
Obtaining a patient file is broader than requesting only a discharge summary. The request should be made to the right person, with the right date range and document groups, and the completeness and legibility of the delivery should be checked. While missing records are being completed and necessary evidence is being preserved, other application periods must be followed separately.
Frequently Asked Questions
Do I need to file a lawsuit to get my file?
No. A patient may exercise the right to examine records and obtain copies without filing a lawsuit.
Can my relative obtain my file on my behalf?
Kinship alone may not be sufficient. Authorization, representation and the institution's identity verification conditions are assessed.
Is it enough to be given only the discharge summary?
Other records that have been requested and fall within the scope of the right of access must also be reviewed separately. The discharge summary does not replace the entire detailed file.
If the file contains wrong information, can I have it completely deleted?
Rights to correction and completion exist; however, statutory retention, the integrity of records and the preservation of evidence are also taken into account. Not every objection requires the untraceable deletion of a past record.
If the records are incomplete, will I definitely win the case?
No. The effect of the missing item on proof and on liability is assessed concretely. It cannot be accepted as if the omission were insignificant either.
Sources and legal bases
- Patients' Rights Regulation (Hasta Hakları Yönetmeliği), Articles 16–17, 21 and 23. Ministry text.
- Law No. 6698 on Personal Data Protection (Kişisel Verilerin Korunması Kanunu), Articles 4, 6 and 11–14. Official legislation.
- Regulation on Personal Health Data (Kişisel Sağlık Verileri Hakkında Yönetmelik), Official Gazette (RG) of June 21, 2019, No. 30808. Ministry legislation link.
- Law No. 4982 on the Right to Information (Bilgi Edinme Hakkı Kanunu), especially Article 11 and the provisions on the privacy of private life. Official legislation.
- Law No. 6100 on Civil Procedure (Hukuk Muhakemeleri Kanunu), Articles 219–221, 400 et seq. Legislation record.
- Constitutional Court, Hasan Kamer, B.2018/11847, June 16, 2021, especially §§37–40 and the operative part. Decision text — De Jure, may require login.
- Regulation Amending the Regulation on Personal Health Data (Kişisel Sağlık Verileri Hakkında Yönetmelikte Değişiklik Yapılmasına Dair Yönetmelik), Official Gazette (RG) of July 4, 2026, No. 33300; Article 13/A added by Article 3. Official Gazette; official announcement by the Ministry of National Education (MEB) reproducing the amended text.