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.
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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: