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Medical
Records Our
work inevitably leads us to the medical records. In fact,
reviewing medical records is often the first and most important
step in every type of investigation or assessment we undertake.
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What are Medical
Records
A
patient record is a history of the management
of their care.
It details what was done
and not done in treating the
patient. The extent and nature of the record for any
given patient will vary according
to the complexity of the problems and the amount of information that
has previously been recorded. All of the information in the record
is invaluable to the patient's ongoing care.
It is also invaluable in investigating the quality of care that was
provided.
Clinical records are
created to enable the health professional to adequately manage the
care of their patients. Medical records provide and preserve
information relating to the treatment, diagnosis and communications
between a doctor (or other medical professional) and his
patient.
The record will usually
include, among other things, a family and personal medical history, the results of any
physical examinations, reports of other consulting physicians,
emergency reports, and progress notes. The
record will also include the results of any tests or investigations
undertaken on behalf of the patient.
Importance of Records
to your Case
Physicians generally see
many hundreds of patients in a year. It would be unreasonable to
expect that they would recall much of any particular patient
visit. As a result, medical records are critical in assisting the
physician to recall what was said, done or recommended at any
specific visit. When records are incomplete or sketchy, this
generally works against the physician.
The patient, on the
other hand, typically has a good recollection of visits. For them,
the visit represents an infrequent and generally important event
in their lives. In the absence of evidence to the contrary,
usually found in the medical records, the patient’s recollection
is most often preferred to that of the doctors.
Good Charting
Accurate, detailed and
complete records are indicative of a thoughtful and diligent
physician. Conversely sparse, illegible records suggest a
physician who has spent little time in assessing and thoughtfully
approaching a patient’s medical problem.
Accessing Records
The Supreme Court of
Canada set out the common law right of the patient to access medical
records of his doctor in the the case of McInerney v. MacDonald,
[1992] 2 S.C.R. 138. In the absence of legislation, patients are
entitled, upon request, to examine and copy all information in their medical records which the
treating physician
considered in administering advice or treatment, including records
prepared by other doctors that the physician may have received. The
patient is not entitled to the records themselves; the physical
medical records of the patient belong to the physician.
Access is also a fundamental
principle of the federal Personal Information and
Electronic Documents Act (PIPEDA) - individuals
have the right to request and see any personal
information physicians hold about them. There are
remedies under this Act for the failure to provide
access to a patient's own records.
Physicians and hospitals
generally must provide a copy of a patient's clinical chart upon
request by a patient or other authorized individual (e.g. a
lawyer). They are permitted to request a written authorization and
generally charge for making the copies.
The College of
Physicians and Surgeons of Ontario requires that all
physicians must allow for access to and
correction of records. A
failure to provide access will usually result in
disciplinary proceedings. A complaint can be made to
the College if access to records are not complied
with in a timely manner. Before lodging a complaint,
the patient should advise the doctor of their
intention to complain and provide the doctor an
opportunity to respond.
If a complaint is
necessary, it must be made in writing identifying the
physician and setting out the circumstances of the
complaint. It should be directed to:
Director, Public
Complaints
The College of
Physicians and Surgeons of Ontario
80 College Street
Toronto, Ontario
M5G 2E2
Charges for Records
There are no specific
regulations dealing with the charges that a doctor or physician
may levy for copying the record. The College of Physicians and
Surgeons of Ontario permits a "reasonable fee" for copying records.
However, a
physician or hospital should not charge the patient
a fee which exceeds the cost of the materials used, the time
required to prepare the material, and the direct cost of providing
the material to the patient.
A physician may not require
prepayment of fees for providing records and non-payment of the fee is not a reason to withhold the information.
Hospitals can and usually do require prepayment of their fee
before releasing the records.
The
Medico-Legal Society of Toronto suggests that a
reasonable fee for photocopying of medical records is
$50 for the first ten pages, and 25 cents per page
thereafter.
Generally, one can
expect to pay between $25.00 and up, from a physician and $100.00
and up from a hospital, depending on the volume of
material and the age of the records. A long hospital stay, might
result in a charge of several hundred dollars.
Retention
of Records
In Ontario
doctor's records must be kept for the greater of 10
years or 10 years after the patient turns 18 years old
(regulations under the Medicine Act). Hospital
records must be kept for the greater of 10 years from
the date of the last visit or 10 years after the patient
turns 18 years old (regulations under the Public
Hospitals Act).
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