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A Review of Patient Records Done Before Billing Is Submitted Is Called

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Medical Records Management

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Approved by Quango: November 2000
Reviewed and Updated: September 2005, November 2006, May 2012, March 2020
Companion Resources: Advice to the Profession

Policies of the Higher of Physicians and Surgeons of Ontario (the "Higher") fix out expectations for the professional conduct of physicians practising in Ontario. Together with the Practise Guide and relevant legislation and case law, they will be used past the Higher and its Committees when considering doctor practice or acquit.

Inside policies, the terms 'must' and 'advised' are used to articulate the College's expectations. When 'advised' is used, it indicates that physicians tin can apply reasonable discretion when applying this expectation to practice.

Additional information, general communication, and/or best practices can exist establish in companion resources, such as Advice to the Profession documents.

Policy

  1. Whether in paper or electronic format, physicians must comply with all relevant legislation1 and regulatory requirements related to medical tape-keeping.

Establishing Custodianship and Accountabilities

  1. Physicians must have a written agreement that establishes custodianship and clear accountabilities regarding medical records if they:
    1. practise in a setting where there are multiple contributors to a record-keeping system (e.g., a group or interdisciplinary practice, settings with a shared electronic medical record (EMR)); or
    2. are not the possessor of the do and/or of the EMR licence.2, 3
  2. Physicians must ensure their agreements:
    1. are in place prior to the establishment of the group practice, business arrangement, or employment, or as soon as possible afterward;
    2. comply with the Personal Health Data Protection Act, 2004 (PHIPA) and with the expectations ready out in this policy; and
    3. address:
      1. custody and control of medical records, including upon termination of employment or the practice organization;
      2. privacy, security, storage, retention, and destruction of records; and
      3. enduring access for themselves4 and their patients.
  3. Physicians with custody or control of medical records must give all onetime partners and associates reasonable access to their patient medical records to permit them to prepare doc-legal reports, defend legal deportment, or respond to an investigation, when necessary.5
  4. Physicians moving to a new practice who do non have custody or control of the medical records of patients who cull to follow them to the new practice, must obtain patient consent to transfer copies of the records to the new location.
  5. Physicians must take all reasonable steps within their control to forestall a disharmonize about medical records from compromising patient intendance.

Access and Transfer of Medical Records

Providing Access to Medical Records

  1. Physicians must provide patients and authorized partieshalf-dozen with access to, or copies of, all the medical records in their custody or command upon request, unless an exception applies.vii, 8
  2. Where an exception applies and access is refused, physicians must inform the individual in writing of the following:
    1. the fact of the refusal;
    2. the reason for the refusal; and
    3. the right of the patient to make a complaint to the Information and Privacy Commissioner of Ontario (IPC).ix
  3. Physicians must provide patients and authorized parties with explanations of whatsoever term, code, or abbreviation used in the medical record, upon request.ten

Transferring Copies of Medical Records

  1. Physicians must retain original medical records for the time period required past the Regulation11 (see Medical Records Retention beneath) and simply transfer copies to others.
  2. Physicians must only transfer copies of medical records where they have consent or are permitted or required by law to do so.12
  3. Physicians must transfer copies of medical records in a timely manner, urgently if necessary, but no subsequently than thirty days after a request.13 What is timely volition depend on whether there is any risk to the patient if at that place is a delay in transferring the records (e.g., exposure to whatsoever adverse clinical outcomes).
  4. Physicians must transfer copies of the unabridged medical record, unless providing a summary or a fractional copy of the medical record is acceptable to the receiving physician and/or the patient.
  5. Physicians must transfer copies of medical records in a secure manner14 and certificate the date and method of transfer in the medical record.15

Fees for Copies and Transfer of Medical Records16

Fulfilling a request for copying and transferring medical records is an uninsured service. As such, physicians are entitled to charge patients or tertiary parties a fee for obtaining a re-create or summary of their medical record.

  1. When charging for copying and transferring medical records, physicians must:
    1. provide a fee estimate prior to providing copies or summaries;17
    2. provide an itemized beak that provides a breakdown of the cost, upon asking (e.g., cost per page, cost for transfer, etc.);xviii and
    3. simply charge fees that are reasonable.
  2. When determining what is reasonable to charge, physicians must ensure that fees:
    1. exercise not exceed the amount of "reasonable price recovery";19 and
    2. are commensurate with the nature of the service provided and their professional costs (i.eastward., reflect the cost of the materials used, the time required to prepare the fabric and the directly toll of sending the cloth to the requesting individual).twenty
  3. When determining a reasonable fee, physicians must consider the recommended fees prepare out in the Ontario Medical Clan'south Medico's Guide to Uninsured Services ("the OMA Guide")21, 22 and the applicable orders of the IPC23.
  4. When determining a reasonable fee, physicians must additionally consider the patient's power to pay.24 In item, physicians must consider the fiscal burden that these fees might place on the patient and consider whether information technology would exist advisable to reduce, waive, or allow for flexibility with respect to fees based on empathetic grounds.25
  5. Physicians may asking pre-payment for records or take action to collect any fees owed to them but must not put a patient's health and safety at run a risk past delaying the transfer of records until payment has been received.26

Retentivity and Destruction

Medical Records Retentiveness27

  1. Physicians must ensure medical records are retained for a minimum of the post-obit time periods28:
    1. Developed patients: 10 years from the engagement of the terminal entry in the record.
    2. Patients who are children: x years after the day on which the patient reached or would have reached 18 years of age.29, 30

Devastation of Medical Records

  1. Physicians must only destroy medical records once their obligation to retain the record has come to an end.
  2. When destroying medical records, physicians must practice so in a secure and confidential manner31 and in such a way that they cannot be reconstructed or retrieved. As such, physicians must, where applicable:
    1. cantankerous-shred all newspaper medical records;
    2. permanently delete electronic records by physically destroying the storage media or overwriting the information stored on the media; and
    3. destroy any redundancy copies of records.32

Storage and Security

Storage

  1. Physicians must ensure medical records in their custody or control are stored in a safe and secure environment33 and in a way that ensures their integrity and confidentiality, including:
    1. taking reasonable steps to protect records from theft, loss and unauthorized access, use or disclosure, including copying, modification or disposal;34
    2. keeping all medical records in restricted access areas or in locked filing cabinets to protect against unauthorized access, loss of information and impairment;
    3. backing-up electronic records on a routine basis35 and storing redundancy copies in a secure environment divide from where the original data is stored.
  2. Where physicians choose to store medical records content that is no longer relevant to a patient's current care separately from the balance of the medical record, physicians must include a notation in the record indicating that documents have been removed from the nautical chart and the location where they have been stored.
  3. Physicians must ensure medical records are readily available and producible when access is required.36

Security37

  1. Physicians with custody or control of medical records must ensure that:
    1. all individuals who have access to medical records are spring by appropriate confidentiality agreements; and
    2. agreements that address data sharing are established for all health intendance providers, organizations or service providers who will have access to or who will exist sharing patient health information with the physician.38
  2. Physicians with custody or control of medical records must have records management protocols that regulate who may gain access to the medical records in their custody or control and what they may do according to their role, responsibilities, and the dominance they accept.39
  3. Accordingly, physicians with custody or control of electronic records must:
    1. ensure each authorized user has a unique ID and password; and
    2. maintain an inspect trail for all accesses (views) of personal health information, even where no changes are made to the record.
  4. When using an electronic record-keeping system, physicians must not share their credentials or passwords.

Electronic Records - Organization Requirements

  1. Physicians must use due diligence when selecting an EMR system and/or engaging EMR service providers and must only use electronic record-keeping systems that:
    1. comply with privacy standards set up out in PHIPA,
    2. comply with the standards set out in the Regulation40, and
    3. can fulfill the requirements set out in this policy and the Medical Records Documentation policy (e.thousand., capturing all pertinent personal health data).41
  2. In item, the Regulation42 requires that physicians must simply use electronic systems that:
    1. Provide a visual display of the recorded information;
    2. Provide a ways of access to the record of each patient by the patient'due south proper noun and Ontario health number, where applicable;
    3. Are capable of printing the recorded information promptly;
    4. Are capable of visually displaying and printing the recorded information for each patient in chronological social club;
    5. Include a password or otherwise provide reasonable protection confronting unauthorized access;
    6. Maintain an audit trail (a record of who has accessed the electronic tape) that:
      1. records the date and time of each entry of information for each patient,
      2. indicates any changes in the recorded information,
      3. preserves the original content of the recorded information when changed or updated, and
      4. is capable of beingness printed separately from the recorded information for each patient;
    7. Automatically support files and allow the recovery of backed-up files or otherwise provide reasonable protection confronting loss of, harm to, and inaccessibility of, information.43
  3. Physicians must be expert with their electronic tape-keeping system in order to:
    1. meet the requirements for record-keeping set out in relevant legislation and this policy; and
    2. participate in all regulatory processes (e.m., College investigations and assessments).

Transitioning Records Management Systems44

  1. When transitioning from i tape-keeping system to another (i.e., a paper-based to electronic system, or from i electronic arrangement to some other), physicians must:
    1. maintain continuity and quality of patient intendance;
    2. continue appropriate tape-keeping practices without interruption;
    3. protect the privacy of patients' personal health information; and
    4. maintain the integrity of the data in the medical record.
  2. To ensure the integrity of the medical tape is maintained, physicians who are transitioning from i tape-keeping system to some other must have a quality assurance process in place that includes:
    1. written procedures that are consistently followed; and
    2. verification that the unabridged medical tape has remained intact upon conversion (e.g., comparing scanned copies to originals to ensure that they have been properly scanned or converted).
  3. Physicians who wish to destroy original paper medical records following conversion into a digital format must:
    1. utilize appropriate safeguards to ensure reliability of digital copies;
    2. salvage scanned copies in "read-only" format; and
    3. destroy medical records in accordance with the expectations gear up out in this policy.
  4. Physicians who use phonation recognition software or Optical Character Recognition (OCR) technology to convert records into searchable, editable files must retain either the original record or a scanned copy for the retention periods ready out in a higher place.
  5. So that complete and upwards to date information is independent in 1 central location, physicians with custody or control of records must:
    1. set a date whereby the new (electronic) system becomes the official record; and
    2. inform all wellness intendance professionals who would reasonably be expected to contribute or rely on the tape of this date.
  6. Physicians must only document in the new system from the official date onward.

Endnotes

ane. Personal Health Information Protection Act, 2004, Due south.O. 2004, c.3, Sched. A (hereinafter PHIPA); Role V of the General, Ontario Regulation 114/94, enacted under the Medicine Act, 1991, S.O. 1991, c. 30 (hereinafter Medicine Act, General Regulation); General, Ontario Regulation 57/92, enacted under the Contained Health Facilities Act, R.S.O.1990, c.one.iii (hereinafter IHFA, General Regulation); Hospital Management, Regulation 965, enacted under the Public Hospitals Deed, R.S.O. 1990, c.P.xl (Public Hospitals Act, Hospital Management Regulation); Personal Information Protection and Electronic Documents Act of Canada, S.C. 2000, c. 5 (hereinafter PIPEDA).

two. Section 14(1) of the Public Hospitals Act sets out that patient medical records compiled in a hospital are the holding of the hospital.  For the purposes of this policy, the provisions gear up out in the Public Hospitals Human activity, along with the terms of a md's hospital privileges can serve every bit the official understanding for physicians who work in hospitals.

3. Additional communication for establishing such agreements can exist institute in the Canadian Medical Protective Clan's (CMPA) Electronic Records Handbook. In particular, the CMPA's Data Sharing Principles and the template titled Contractual Provisions for Information Sharing can be reviewed and serve as a model. The OMA can also provide assistance establishing contracts.

4. Come across PHIPA, s. 41(1) for the specific circumstances where physicians are permitted admission to the personal health information of their one-time patients.

5. See PHIPA, south. 41(1) for the specific circumstances where access can exist provided to former partners and associates.

6. Authorized parties include substitute decision-makers and estate trustees/executors of the manor where applicable, and 3rd parties where consent has been obtained.

7. PHIPA, s. 52; Department 52 of PHIPA contains a comprehensive list of the exceptions.

eight. In that location are exceptions that may limit the data a medico is required to produce in the context of an independent medical examination. For more information, please refer to PIPEDA. The CMPA'south article, Providing access to independent medical examinations also sets out communication on this issue.

ix. PHIPA, due south. 54(1)(c). When access is refused on sure grounds, there are exceptions to the type of information that must be provided to patients. See PHIPA, due south.54(1.1) for more information.

10. PHIPA, s. 54(ane)(a).

xi. Medicine Human action, General Regulation, s. nineteen(ane).

12. For more than information regarding disclosure, please refer to the Higher'south Protecting Personal Wellness Data policy.

13. PHIPA, s. 54(2). Physicians are required nether PHIPA to respond to requests of records transfer as soon equally possible, but no later than thirty days of the request. Sections 54(3) and 54(5) of PHIPA set out provisions for circumstances requiring expedited access and an extension.

14. PHIPA, southward. 13(1).

15. For more data on transferring records, please meet the Advice to the Profession: Medical Records Direction certificate.

sixteen. These requirements apply regardless of whether access is provided directly by a physician or an agent of the physician, such equally a records storage company.

17. PHIPA, southward. 54(10).

18. It is an act of professional misconduct to fail to provide an itemized invoice when asked (See s. 1(1) paragraph 24 of Ontario Regulation 856/93Professional Misconduct, enacted under theMedicine Deed, 1991S.O. 1991. C.30 (hereinafter Professional Misconduct Regulation).

19. PHIPA, s. 54(xi).

twenty. In accordance with s. 1(1), paragraph 21 of theProfessional Misconduct Regulation it is an act of professional misconduct to charge a fee that is excessive in relation to the services provided.

21. The OMA Guide is typically updated annually, and so physicians must ensure they take reviewed the nearly contempo edition.

22. While physicians are not obliged to prefer the recommended fees set up out in the OMA Guide, in accordance with s. 1(1) paragraph 22 of theProfessional Misconduct Regulation, it is an act of professional person misconduct to charge more than the current recommended fees in the OMA Guide without first notifying the patient of the backlog amount that volition be charged.

23. See IPC Orders HO-009 and HO-14.

24. The Canadian Medical Association's Lawmaking of Ethics and Professionalism (#26) states that physicians accept an upstanding and professional responsibility to "Discuss professional fees for non-insured services with the patient and consider their ability to pay in determining fees."

25. For more than information on how to determine a patient's ability to pay, please refer to the Advice to the Profession: Medical Records Management document.

26. For additional guidance on fees delight refer to the College'due south Uninsured Services: Billing and Block Fees policy.

27. There are separate provisions for the retention of certain records, including the following:

  • Physicians who cease to practise family medicine or primary care have specific retention requirements under southward. 19(1)(2) of the Medicine Act, General Regulation; see the College's Closing a Medical Practice policy for more information.
  • Hospitals take separate retention schedules for diagnostic imaging records; see due south. 20(4) of the Public Hospitals Act, Hospital Management Regulation for more information.
  • Contained health facilities have split retention schedules for patient health records; meet southward. 11(1) of the IHFA, Full general Regulation for more information.

28. Retention requirements utilize every bit to the medical records of patients who are living and deceased.

29. Medicine Act, General Regulation, due south. 19(1).

30. When a request for access to personal health information is made before the memory menses ends, physicians are obligated under section 13(2) of PHIPA to retain the personal health data for equally long as necessary to allow for an individual to take any recourse that is available to them under PHIPA. This may require physicians to retain records longer than the higher up fourth dimension periods, in some instances. Furthermore, south. 15(two) of the Limitations Act, 2002, S.O. 2002, c. 24, Sched. B allows for some legal proceedings to be brought forrad 15 years later on the act or omission on which the claim is based took place and thus physicians may wish to retain records for longer than the 10 twelvemonth requirement.

31. PHIPA, south. 13(i).

32. For further data, see south. 13(1) of PHIPA and the IPC'due south Fact Sheets on Secure Destruction of Personal Information and Disposing of Your Electronic Media.

33. PHIPA, due south. 13(ane).

34. PHIPA, s. 12(i). What is reasonable in terms of records management protocols volition depend on the threats and risks to which the information is exposed, the sensitivity of the data, and the extent to which it tin can be linked to an identifiable individual.

35. The CMPA suggests daily or weekly back-ups be considered. The CMPA provides risk management advice regarding redundancy and recovery practices for EMR systems in its Electronic Records Handbook.

36. This includes where physicians rely on an external facility or organization, such as a commercial storage provider, diagnostic facility, or dispensary to retain records.

37. For expectations related to privacy breaches please refer to the College'southward Mandatory and Permissive Reporting policy.

38. The CMPA'due south Electronic Records Handbook contains communication for creating data sharing agreements.

39. Records management protocols include both physical and logical access controls. Physical admission controls are concrete safeguards intended to limit persons from entering or observing areas of the medico'southward office that comprise confidential health information or elements of an EMR system. Logical access controls are system features that limit the information users can access, modifications they can make, and applications they can run. Examples of the latter include the use of "lockboxes" and "masking" options to restrict access to personal wellness information at a patient's asking.

40. Medicine Act, General Regulation, s. 20.

41. Employ of EMRs that are certified by OntarioMD can aid ensure compliance with this expectation. Please see the Advice to the Profession: Medical Records Management document for more information on the benefits of using EMRs that are certified past OntarioMD.

42. Medicine Human action, General Regulation, s. twenty.

43. Medicine Human action, General Regulation, s. 20.

44. For boosted guidance related to transitioning record-keeping systems please refer to the companion Communication to the Profession: Medical Records Management certificate.

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Source: https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Medical-Records-Management

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