Guidelines

The Patient Medical Record Guideline

 

• 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:
     
     1. The name, address, and date of birth of the patient;
     2. For a consultation, the name and address of the primary care physician and of any health professional who referred the patient;
     3. Every report received respecting the patient from another member or health professional;
     4. The date of each professional encounter with the patient;
     5. A record of the assessment of the patient, including,
        
        1. the chief complaint or reason for the assessment;
        2. the history obtained by the member;
        3. the particulars of each medical examination by the member; and
        4. a note of any investigations ordered by the member and the results of the investigations.
           
           

     6. A record of the diagnosis or provisional diagnosis;

     7. A record of the disposition of the patient, including,

        1. an indication of each treatment prescribed or administered by the member;
        2. a record of professional advice given by the member; and
        3. particulars of any referral made by the member.
     8. Where appropriate, a cumulative patient profile or consolidated problem list is recommended;
     9. A record of all fees charged which were not in respect of insured services may be kept separately from the clinical record.
        
        
  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:
     1. legibly written or typewritten or, if in an electronic data base, available to be produced in hard copy; and kept in a systematic manner; and
     2. kept in a manner which maintains security from unauthorized access.

  
  Ownership of Records
  Usually the physician who prepares the record also owns the record. However, in some cases the physician works for an organization which may own the record. Sometimes a group of physicians may all share the record. Physicians are encouraged to clarify these issues prior to any potential dispute.
  
  The Patient's Right of Access
  The patient has a right to inspect the medical record and obtain copies of it. This includes records of their own physician, as well as of physicians seen at the request of third parties, such as insurers. Patients are not entitled, as of right, to remove the record from the physician's premises. The physical record belongs to the physician. Patients may not alter the existing record. Amending entries may be made, but only by additions acceptable to the physician. It is recommended that at all times the physician or a member of the physician's staff supervise the patient while the original record is being examined. The physician may require the patient to book an appointment to inspect the record and a private area should be provided for this purpose at the physician's office. Prior to providing a record to a patient, the physician should examine the record to make sure that none of the physician's personal material or information concerning other individuals is improperly included in the record.

  The patient is entitled to a copy of all or part of the record.

  
  Denial of Access
  The right to access is not absolute. If the physician reasonably believes that it is not in the patient's best interest to inspect the medical record, the physician may deny access. Physicians should only refuse access where there is a significant likelihood of substantial adverse effect on the physical, mental or emotional health of a patient or harm to a third party. Such references may be deleted or removed from the copied material. The onus to justify a denial of access is on the physician. If access is refused, the physician must provide a reason to the patient, preferably in writing. The physician should be aware that such a refusal may give rise to a complaint to the College.
  
  Consultant Reports/«Confidential» Stamps
  Consultant reports or records received from physicians or other parties are part of the patient's medical record. The physician is not obligated to notify a consultant of the patient's access. Stamps or typed directives suggesting that the material has special confidential status have no meaning and do not affect the way the material should be handled.
  
  Fees

  It is ethical for a physician to charge a reasonable fee which should be explained to the patient in advance for:

  • Reviewing the record prior to making it available for inspection; Making a staff member available to supervise the patient's inspection of record;
  • The physician is not required to be present to explain the record. If the physician is asked to do this by the patient, the physician is entitled to charge a reasonable fee for this service.

  Copying charges
  Costs associated with the provisions or transfer of information may be assessed to the patient either directly or through the requesting physician. If the patient is unable to pay these reasonable costs due to financial difficulties, then the physician would be expected to waive or reduce the charges. It is not considered ethical to make a profit on medical records. It is also not considered ethical to demand payment of any such fees in advance.

  
  Confidentiality and Transfer
  Information in the files is considered confidential between the physician and the patient, except where disclosure is required by law or requested by the patient. Appropriate patient consent is required for any release of information by a physician except where the law requires a report (e.g. certain communicable diseases) or when a court order directs the physician. When a patient comes under treatment of a second physician, either in consultation, or as a result of a change in primary attending physician initiated by the patient, it is assumed that the patient would normally wish a free exchange of any information relative to the present condition. Where feasible, it is desirable to have a signed consent for this exchange, but insistence on prior signed consent must not interfere with the flow of essential information. It is rarely necessary to transfer entire records. In some circumstances it may be expedient to loan the original record to the current attending physician to be returned to the originating physician within a reasonable time.

  All arrangements for transfer of information should be made directly between the physicians concerned. Where it is the only extant record, the transfer of such records should be made by some secure means.

  
  Third Party Requests
  When physicians are requested to provide access to, or a copy of, a record to a third party, physicians should ensure that they receive a signed consent from the patient which specifically provides for access to the record and/or a copy of it. If the direction from the patient is not clear, then clarification should be obtained from the patient.

  
  Retention of Records
  The original records should be retained under the control of the physician who made them. Each physician who has contributed to group records should have continued direct access to those records. The physician has no right to sell specific records to succeeding physicians. Neither has the patient the right to require that the original record be transferred to a second physician.

  All medical records of adult patients should be retained for a period of at least ten years after the last entry. Records of children should be retained to the age of majority plus two years. Exceptions to these requirements might include records which are otherwise available through a hospital, or, in the case of consultants, through the family physician. Finally, records of deceased patients may be destroyed two years after death. Regardless of these rules, however, certain records may be retained if the information they contain suggests future access may still be required. Physicians should keep a record of all records which have been destroyed.

  Transfer From Paper to Electronic Records

Physicians will now be allowed to scan and keep electronic copies of all records, allowing the originals to be destroyed in an appropriate fashion.  Copies can then be generated from the electronic version when necessary.

Disposal of Records

When the decision is made to dispose of records, this must be done in a manner which preserves confidentiality, such as by supervised incineration or shredding.

Wills and Records

All members should give serious thought to the manner in which their records will be handled in the case of unexpected death or incapacity.

Termination of Practice

There are several acceptable scenarios which physicians may follow should they terminate practice, either because of relocation or retirement.

Regardless of the approach taken, the primary concerns should be that the continuity of patient care can be assured and that patient records are maintained. The accessibility of these records to appropriate parties should also not be impeded. Thus, these concerns mainly relate to family practitioners. However, the principles, if not the implementations, are the same for many specialty practices as well.

If a physician leaves a practice, the records may be maintained by a physician who remains at the same address and telephone number. The original physician must be assured access to these charts. In the case of family practitioners, as a courtesy, patients should be advised that the new physician has taken over the practice. If the new physician does not intend to assume care of all the patients whose charts have been retained, they must be advised directly.

In the case of group practices, the ownership of a physician's charts should be clarified from the outset as part of the agreement under which the physician joins the group. This should avoid difficulties which may arise later. If the remaining members of the group retain the charts, the physician who is leaving must be guaranteed access.

In other circumstances, the physician may arrange for the charts to be retained by a custodian, such as another physician. Records, however, should never be sold as such.

Finally, the physician may retain his or her original charts. This is discouraged if the physician is relocating out of province as access to the records may thus be compromised.

In all circumstances, the College should be notified of the arrangements the physician has made for the charts upon termination of the practice. In addition, hospitals and colleagues should be advised as well. If the charts are to no longer be available at the original office, family practice patients should be advised directly of this. A newspaper advertisement is not considered sufficient for this purpose.

If the original physician does not retain the records, but has transferred them to a custodian, there should be a written agreement regarding the retention, transfer, and, where appropriate, destruction of the records. That is, the duration of time the records are to be retained should be made clear. When information is requested from the records, the ability of the custodian to charge a reasonable fee for this should be provided for. When sufficient time has passed to allow some or all of the records to be destroyed, the circumstances under which this should be done should be clarified. For example, a list of all records transferred or destroyed should be maintained by the custodian.

Suggestions for agreements regarding such custodial arrangements may be obtained from the College.

Where a practitioner, or his or her estate, or the custodian of records, has difficulty retaining files under these guidelines, the College should be contacted to consider other arrangements

4/08

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