Management of Medical Records

Preamble

Medical Records FAQs

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, physicians are referred to the Professional Standards and Guidelines Regarding Charting.

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

While physicians own medical records, patients have a right to access their medical records. This right endures after the physician-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 physician.

In addition to the provisions of this Standard, physicians must also comply with all legislative, ethical and regulatory requirements related to medical record-keeping, including the Personal Health Information Act. Physicians are encouraged to seek advice from the Canadian Medical Protective Association (CMPA) regarding questions of patient record management.

Professional Standards

1. Access to Medical Records

1. All physicians, 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. Physicians 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 physician leaves the practice.

2. Transferring of Medical Records

When transferring medical records, physicians must:

1. Transfer copies of medical records in a secure manner, documenting the date and method of transfer in the medical record; and
2. Charging a fee, ensure the fee is reasonable, reflecting the time and resources required of the physician and staff.

3. Retention and Destruction of Records

1. In the case of minors, physicians 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 relevant, whichever is later.
2. In the case of patients who are not minors, physicians 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. Physicians must only destroy medical records once their obligation to retain the record has come to an end.
4. Physicians must destroy medical records in a secure and confidential manner and in such a way that they cannot be reconstructed or retrieved.

4. Storage and Security

Physicians 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;
2. Backing-up electronic records on a routine basis and storing back-up copies in a secure environment separate from where the original data is stored; and
3. Ensure medical records are readily available and producible when access is required.

5. Electronic System Record Requirements

Physicians 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:

3. 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.

Resources

Canadian Medical Protective Association

• How to Manage Your Medical Records: Retention, access, security, storage, disposal and transfer
• My patients, my records?
• Electronic Records Handbook (PDF)
• Who has custody of medical records, and who can they be shared with?

College of Physician and Surgeons of Nova Scotia

• Professional Standards Regarding Temporarily or Permanently Closing a Medical Practice
• Information Sharing Agreement Template

Government of Canada

• The Personal Information and Electronic Documents Act

Government of Nova Scotia

• Personal Health Information Act
• Duties of a Custodian (PHIA)