Dialogue Volume 15, Issue 3 2019 - Page 32

POLICY MATTERS MEDICAL RECORDS STEWARDSHIP Two drafts now out for consultation O ur most referenced policy – the Medi- cal Records policy – has been re-or- ganized and divided into two, newly titled draft policies that cover distinct topics related to medical records. Both drafts have been approved for external consultation. The Medical Records Stewardship draft sets out expectations related to the care, handling and man- agement of medical records, particularly related to access and transfer, security and storage, and reten- tion and destruction of records. The second draft policy, Medical Records Docu- mentation, sets out expectations related to how and what to document in medical records. The draft focuses on foundational principles for document- ing the patient encounter (i.e., legibility, accuracy, comprehensiveness and timeliness) and the required content of all records. A companion Advice to the Profession document has been developed for each policy. 32 DIALOGUE ISSUE 3, 2019 • Physicians who practise in settings with multiple contributors to a record-keeping system are required to have written agreements that set out custodianship and clear accountabilities for records • Physicians who are not the custodian of the record and who leave a group practice are required to obtain patient consent to transfer the records of patients who are following them • Physicians must not allow conflicts over records to impact patient care Refusing Access to Medical Records In those rare instances when a physician may/is permit- ted to refuse a patient access to their records, the draft includes a legal requirement to notify the patient in writing of the refusal and the reason for refusal and to inform the patient of their right to make a complaint to the Information and Privacy Commissioner. Timely Transfer of Records Physicians are required to transfer copies of records in a timely manner, urgently if necessary, but no later than 30 days after a request. The draft sets out that what is timely will depend on whether there is any risk to the patient if there is a delay in transferring the records (e.g., exposure to any adverse clinical outcomes). Medical Records Divided into Two Distinct Topics Establishing Custodianship and Accountabilities In response to frequent complaints, disputes, and am- biguity regarding ownership of records, particularly in settings with a shared EMR, the draft policy includes the following: