2023 Laws of Puerto Rico › TITLE TWENTY-FOUR - Health and Sanitation (§§ 1 — 15010) › PART VIII - Mental Health (§§ 4001-6151 — 6184) › Chapter 201A - Mental Health Code of 2000 (§§ 6152 — 6166g) › Subchapter II - General Responsibilities of Mental Health Service Providers and General Provisions for Adults and Minors (§§ 6153 — 6153y) › § 6153g - Inspection of clinical record

Persons who receive mental healthcare services may inspect their clinical records inasmuch as the mental health science professionals who provide outpatient services at their private offices or the inter- or multidisciplinary team within an institution determines that the person who receives the services is capable of interpreting the information reasonably; Provided, That no information shall be provided when it may constitute a risk to the person who receives the services and/or to third parties. He/She may also have a copy of the complete record upon written request to that effect and payment of the corresponding fees; being the inclusion on clinical grounds of the psychotherapy notes, as these are defined in this chapter, at the discretion of the mental healthcare professional and/or the interdisciplinary team. The institutional provider shall assign a mental healthcare professional to explain any matter relative to the information contained in the clinical record. If, in the judgment of the mental health science professionals that render services to the patient, the patient is not fit to receive his/her complete record, such a determination shall be notified to the patient or to his/her guardian or caregiver; in default thereof, a petition shall be filed before the Court of First Instance for an appointee. Furthermore, the Court of First Instance shall review the determination whereby the surrender of the complete record is denied and adopt the measures it deems pertinent. Provided, That the mental healthcare professionals who render services to the patient shall not be held civilly liable for their refusal to surrender the complete record in those cases in which the court has intervened.
Any other person expressly authorized, as provided in this chapter, by the person who receives mental healthcare services, by the court or by his/her legal guardian, may inspect the clinical record at the institution, obtain a summary of the record and a copy of any document expressly authorized upon payment of the corresponding fees, insofar as the reproduction of the documents does not constitute the complete record or those documents expressly prohibited under this chapter.
The right to confidentiality of the patient may only be forgone in those cases expressly contemplated under this chapter.
The parent with legal or physical custody or the legal guardian of the minor who receives mental healthcare services, shall have the right to examine, at the institution, said minor’s record exclusively in matters relative to the diagnosis, severity, prognosis, treatment plan, medications, recommendations to the family, and the amount and kinds of therapy offered. Any other information requested by these persons shall have the express authorization of the minor if he/she is fourteen (14) years of age or older, or of the court when the minor does not authorize the inspection of the information requested, or if the minor is thirteen (13) years of age or younger. In addition, he/she may obtain a copy or a summary thereof upon written request to that effect and the payment of the corresponding fees.
When the person who received mental healthcare services dies, any request presented by a family member, up to the fourth degree of consanguinity or affinity, to inspect or obtain a copy of any part or the complete record, shall require a court order.
In all cases, and upon any inspection or copy of the record, the institutional provider shall offer guidance as to the possible consequences of disclosing the information contained in the record.
The corresponding payment for copies of any part or the complete record shall not exceed seventy-five cents (75¢) per page or twenty-five dollars ($25) for the complete record. For those cases in which the person does not have the financial means to pay for the cost of the copies, the procedure to follow shall be established through regulations by the Administration.
History —Oct. 2, 2000, No. 408, § 2.08; Aug. 6, 2008, No. 183, § 7.