The Patient Medical Record Guideline
This guideline is intended to incorporate College policies, prevailing practices, and the provisions of the Personal Health Information Protection and Access Act (PHIPAA).
Content of records
For records of physicians in private practice, College regulations require the following:
1. A member shall make records for each patient containing the following information:
a. The name, address, and date of birth of the patient;
b. For a consultation, the name and address of the primary care physician and of any health professional who referred the
c. Every report received respecting the patient from another member or health professional;
d. The date of each professional encounter with the patient;
e. A record of the assessment of the patient, including,
i. the chief complaint or reason for the assessment;
ii. the history obtained by the member;
iii. the particulars of each medical examination by the member; and
iv. a note of any investigations ordered by the member and the results of the investigations.
f. A record of the diagnosis or provisional diagnosis;
g. A record of the disposition of the patient, including,
i. an indication of each treatment prescribed or administered by the member;
ii. a record of professional advice given by the member; and
iii. particulars of any referral made by the member.
h. Where appropriate, a cumulative patient profile or consolidated problem list is recommended;
i. A record of all fees charged which were not in respect of insured services may be kept separately from the clinical
2. A member shall keep a continuous record containing the name of each patient who is encountered professionally or treated or for whom a
professional service is rendered by the member.
3. The records required by regulation shall be:
a. legibly written or typewritten or, if in an electronic data base, available to be produced in hard copy; and
b. kept in a systematic manner; and
c. kept in a manner which maintains security from unauthorized access.
Retention of Records
Physicians are expected to provide for retention of their own records, whether in hard copy or electronic format, for certain minimum periods of time. Generally, records should be retained for a period of ten years after the patient is last seen. In the case of minors, records should be retained for a period of ten years after the patient has been last seen, or until the age of twenty-one, whichever is longest. In the case of deceased patients, records should be retained for a period of two years following the date of death.
Theft, Loss, or Disclosure of Records
Physicians are expected to maintain the strictest possible security for patient information and to take all reasonable efforts to protect such information from theft, loss, or other forms of disclosure. When, despite such efforts, theft, loss, or the potential for disclosure does occur, PHIPAA requires the physician to advise all patients potentially affected of the potential for disclosure of their information. PHIPAA does provide that this notification is not necessary if the physician reasonably believes there will be no disclosure of the patient’s information, nor any other adverse impact on the patient.
Destruction of Records
Following the above noted time periods, patient records may be destroyed in an appropriate manner, generally by supervised shredding or incineration. The physician is required to maintain a list of each record that is destroyed, with a description of the time period covered in the record.
Access to Records
PHIPPA requires that, upon request, the patient be granted access to review their record within thirty days. Access should generally be granted with appropriate supervision, but under PHIPAA, there can be no extra charge for such access.
The patient may request the assistance of the physician in interpreting the record. Physicians are obligated to provide this service when requested. If such a request is relevant to the patient’s health care, such assistance can be considered an insured service. If the record is reviewed for another purpose, the physician may be entitled to invoice the patient directly for the time spent.
It should be noted that, while patients are entitled to be provided assistance in understanding the content of the record, PHIPAA does not entitle the patient to a translation of the record, or any part of it, to another official language.
Also under PHIPAA, patients are entitled to a copy of their complete record within thirty days of a request. Regulations under PHIPAA provide a maximum charge of .25/page, with no additional fees for retrieval. Postage or courrier services may be recovered at actual costs.
Denial of Access
Under PHIPAA, a patient may be denied access to a copy of a portion of records for a number of reasons. The most common would be where disclosure of such information would create a risk of harm to the patient or others. On this basis, when otherwise providing access, or a copy, a physician should sever such information from the rest of the record.
Generally, any information forwarded to the physician from any source regarding a patient becomes part of the patient’s record. Notations which preclude copying or forwarding any particular document are of no force or effect.
Nevertheless, PHIPAA does provide that, when information is provided by a third party, and there is a clear sense it is provided in confidence, the patient may be denied access to this information. This may mainly apply to information received from family members, and others with a direct relationship to the patient.
Correction of Records
Correction of records after their production is generally considered improper. However, PHIPAA does provide a mechanism for patients to request corrections to their records. If the physician agrees to such a correction, it should generally be in the form of an addendum to the record so the fact of the change is clear. If the physician objects to the request for a correction, such objection must be recorded and become part of the patient’s record. If a correction, or refusal of a correction, occurs following the transfer of information to another party, the latter must be advised of the change or the physician’s refusal.
Transfer of Information
Transfer of relevant information among physicians, and others directly involved in the patient’s care, must always be expedited in the patient’s best interest. In the normal course of health care delivery, such should occur without the need for express consent from the patient or their personal representative. Information relevant to the patient’s well being should, thus, be shared within the “circle of care” of the patient.
Where information is transferred to any other party, or for any other reason, such should be done with a clear express consent of the patient or another person entitled to act in their stead, according to the provisions of PHIPAA. The physician should be satisfied as to the true intent of the direction, such as whether all, or part of a record is to be forwarded. Any uncertainty should be clarified with the patient.
Transfer of Records between Physicians
In accessing the services of a new physician, the patient is entitled to have information relevant to their health care forwarded without impediment and in a timely fashion. In other words, the original physician should be prepared to forward information necessary for the patient’s ongoing treatment in a timely fashion. The physician in entitled to invoice the patient for this service as long as such is done on a fair and reasonable basis.
To expedite the transfer of information, and to limit the costs involved, physicians are encouraged to avoid copying the entire record, but, instead, to forward only necessary information regarding significant issues and current status.
Requests from transfer of patient information should generally be honoured within six weeks, or less if circumstances require.
Termination of Practice
When a physician’s practice closes due to retirement, relocation, or death, the storage and distribution of records can represent significant challenges. PHIPAA requires that patients in active treatment be given reasonable notice of the location of their records for the purpose of eventual access. In addition, it is expected that physicians will also advise the College of the location of the records after their practice closes.
In any case, original records should be secured in a manner that is reasonably protected from any potential damage. It is also acceptable for physicians to retain copies of the records in an electronic format following appropriate destruction of the originals. Physicians may also use the services of an acceptable document storage agency. If the physician relies on a third party for retention and storage of any records, such should be done on the basis of a clear obligation for patient access, as well as clear a clear process if the third party becomes unable to continue providing the service.
It should be noted that, where records have been found abandoned, or are otherwise at risk of disclosure or destruction due to a lack of provisions for their storage, the College has authority to seize such records by a Court order.
Physicians should make special note of the difficulties which can arise for surviving family regarding the retention of records following the death of a physician, whether before or after they have retired from practice. Physicians are encouraged to make appropriate arrangements and provide appropriate instructions to minimize such difficulties.Adopted 4/96; amended 4/08; 6/10