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Management of Medical Records for Podiatrists

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Professional Standards Regarding the Management of Medical Records for Podiatrists

Preamble

The purpose of this Standard is to set out the College’s requirements regarding the management of patient medical records. With respect to the contents of medical records, podiatrists are referred to the Professional Standards and Guidelines Regarding Charting for Podiatrists.

Whether in paper or electronic form, from the moment a patient record is created, the podiatrist has a responsibility to ensure it is appropriately stored, secured, and maintained.

While podiatrists own medical records in their practice, patients have a right to access their medical records. This right endures after the podiatrist-patient relationship ends, regardless of whether the ending is planned or unexpected.

For the purpose of this Standard, a patient’s enduring right to access their own medical record is limited to the length of time when records are required to be retained by their podiatrist.

In addition to the provisions of this Standard, podiatrists must also comply with all legislative, ethical and regulatory requirements related to medical record-keeping, including the Personal Health Information Act. Podiatrists are encouraged to seek advice from legal counsel regarding questions of patient record management.

Professional Standards

  1. Access to Medical Records
  1. All podiatrists, irrespective of practice setting, must take reasonable steps to ensure there is a process in place establishing reasonable and enduring access for patients to their charts.
  2. Podiatrists in group practices must have agreements in place to ensure the enduring right of patients to access their charts in the event the practice closes or their podiatrist leaves the practice.
  A document outlining the use of an Information Sharing Agreement, and template for such an agreement is attached as Schedule “A” to this Standard. It should be adapted for the particular circumstances of the podiatrist’s practice.  
  1. Transfer of Medical Records

When transferring medical records, podiatrists must:

  1. Transfer copies of medical records in a secure manner, documenting the date and method of transfer in the medical record; and
  2. If charging a fee, ensure the fee is reasonable, reflecting the time and resources required of the podiatrist and staff.
 Fulfilling a request for copying and transferring medical records is an uninsured service. Podiatrists are entitled to charge patients or third parties a fee for obtaining a copy or summary of their medical record. Patients should be made aware in advance of fees. The charge should reflect the cost of the materials used, the time required to prepare the materials, the direct cost of sending the materials and the patient’s ability to pay.  
  1. Retention and Destruction of Records
  1. In the case of minors, podiatrists must retain medical records for at least ten (10) years from the time the patient reaches the age of majority, which is 19 in Nova Scotia, or the completion of any known proceedings where the records may be relevant, whichever is later.
  2. In the case of patients who are not minors, podiatrists must retain medical records for at least ten (10) years from either the date of the last entry or the completion of any known proceedings where the records may be relevant, whichever is later.
  3. Podiatrists must only destroy medical records once their obligation to retain the record has come to an end.
  4. Podiatrists must destroy medical records in a secure and confidential mannerand in such a way that they cannot be reconstructed or retrieved.
  1. Storage and Security

Podiatrists must:

  1. Ensure medical records in their custody or control are stored in a safe and secure environment, ensuring their integrity and confidentiality, by:
  1. taking reasonable steps to protect records from theft, loss, and unauthorized access, use or disclosure, including copying, modification, or disposal; and
  2. keeping all medical records in restricted access areas or in locked filing cabinets to protect against unauthorized access, loss of information, and damage;
  1. Backing-up electronic records on a routine basisand storing back-up copies in a secure environment separate from where the original data is stored; and
  2. Ensure medical records are readily available and producible when access is required.
  3. It is incumbent upon every Podiatrist to understand their obligations regarding medical records regardless of their particular employment circumstances or arrangements with a clinic.
  1. Electronic Records System Requirements

Podiatrists must:

  1. Use due diligence when selecting an Electronic Medical Record (EMR) system and/or engaging EMR service providers;
  2. Only use EMR systems that:
  1. ensure appropriate security provisions are in place;
  2. provide a means of access to the record of each patient by the patient’s name (and Nova Scotia health number, where applicable);
  3. include a password or otherwise provide reasonable protection against unauthorized access; and
  4. maintain an audit trail (a record of who has accessed the electronic record) that:

(i) records the date and time of each entry of information for each patient,

(ii) indicates any changes in the recorded information,

(iii) preserves the original content of the recorded information when changed or updated, and

(iv) is capable of being printed separately from the recorded information for each patient;

  1. Automatically back up files and allow the recovery of backed-up files or otherwise provide reasonable protection against loss of, damage to, and inaccessibility of, information.

Definitions

Medical Records means paper-based and electronic medical records as defined in the College’s Professional Standards and Guidelines Regarding Charting for Podiatrists.

Resources

Canadian Medical Protective Association

College of Physician and Surgeons of Nova Scotia

Government of Canada

Government of Nova Scotia

Acknowledgements

The development of this College Standard was informed by the College of Physicians and Surgeons of Ontario’s document Medical Records Management and the College of Physicians and Surgeons of British Columbia’s Practice Standard Medical Records Management.

Document History

First approved by the Council of the College of Physicians and Surgeons of Nova Scotia: March 21, 2025

© 2025 College of Physicians and Surgeons of Nova Scotia