RETAINING AND TRANSFERRING

RETAINING AND TRANSFERRING

Generally speaking, physicians must always keep the
original medical record themselves. Only copies of the
record should be transferred to others.

Retaining Medical Records
Regulation requires that physicians keep medical
records for a certain period of time. For adult
patients, the rule is that records must be retained for
10 years from the date of the last entry in the record.
For patients who are children, the regulation requires
that the physician keep the record until 10 years after
the day on which the patient reached or would have
reached the age of 18 years. However, it is prudent to
maintain records for a minimum of 15 years because,
in accordance with the Limitations Act, some legal
proceedings against physicians can be brought 15
years after the act or omission on which the claim is
based took place.11
Physicians may also be required to retain records
longer than the above time periods when they receive
a request for access to personal health information.
Where such a request has been made, physicians must
retain the personal health information for as long as
necessary to allow for an individual to take any
recourse that is available to them under PHIPA.
The retention rules are different for physicians who
cease to practise medicine, please see below for more
detail. See Appendix A for the applicable regulation.

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Three Different Types of External Review

Three Different Types of External Review

Medical records must meet expectations for three different
types of external review: quality assurance, legal,
and auditing. A good record will provide enough
information to satisfy inquiries made by any of these
bodies. The following specific examples of information
to be included in records of particular types of
encounters may assist physicians in understanding
what is required to ensure that their records are sufficient
for all purposes.

The Periodic or Annual Health Examination
Primary health care providers conduct periodic (or
annual) health examinations for health maintenance
and disease screening. The difference between these
examinations and the more frequent physician/patient
encounter is that these examinations are more comprehensive.
This must be reflected in the medical
record.
This type of encounter should be recorded as a periodic
health exam. It is advisable to use the CPP to
review and update the patient’s medical history, family
and social history, ongoing health concerns or problem
list, immunizations, allergies, and medications.
(The purpose of taking the family and social history is
to generate a risk profile for diseases based on age, gender, family history, and occupation.
The risk profile
serves to direct further history-taking, the physical
examination and screening tests, as well as necessary
patient education and health promotion). The record
should show evidence that appropriate screening and
preventive care is taking place as the patient progresses
through his or her life.
The physical examination should include all body
parts and systems appropriate to the age and gender
of the patient.
The treatment plan, if any, including tests or procedures
ordered and any advice given, should also be
documented.
Discussion of treatment options, explanation of significant
complications and potentially serious adverse
effects of medications should also be included in the
chart, along with referrals to other health care professionals,
where applicable.

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Patient Non-Compliance or Failure to Attend Appointment

Patient Non-Compliance or Failure to Attend Appointment

Physicians should document all instances of a patient
refusing an examination. Most physicians have had an
experience where a patient has refused to have an
examination or a specific portion of an examination,
or asked to defer the examination to a later date. It is
essential that physicians document all advice, tests or
treatments that are refused or deferred by the patient
to ensure that anyone who reads the medical record
will receive an accurate depiction of the treatment that
the patient has received, and will gain an understanding
of the treatment decisions the patient has made.
Where treatment has been refused or deferred, the
medical record should also indicate the reason, if any,
given by the patient for declining the advice and treatment
recommendations of the physician, as this information
may be important for the future care of the
patient.
The medical record should also note when a scheduled
appointment is missed by a patient.

Telephone Conversations and E-Mails
Ideally, all telephone calls would be recorded in the
patient’s chart. It is strongly recommended that telephone
calls dealing with matters of significant clinical
impact that are made to or received from the patient
be documented. The documentation should include
the date and time of the call, significant information
and advice provided. Records should also indicate any
prescriptions or repeats authorized over the telephone.
The CMPA emphasizes the importance of documenting
phone calls as evidenced by its development of a
“Patient Telephone Call Record,” available free-ofcharge
to members. This note-sized sheet has a selfadhesive
portion that allows the physician to affix the
completed note into the patient’s medical record.
There are a few good reasons for including phone calls
in the medical record because they:
• Will assist in providing better continuity of care;
• Could provide significant evidence in lawsuits, hearings
or inquests when provision of patient care
might be in question;
• Serve as fundamental components of external
reviews relating to quality of care, and inquiries such
as those made by the Coroner’s Office, etc.
Records of e-mails to and from patients should be
treated in the same way as records of telephone calls.
Where possible, it is advisable to copy all correspondence
for the chart, particularly those dealing with
matters of significant clinical impact.

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