Medical Records

What is a medical record?

A medical record is a file that contains information about a single patient, including demographic information, his/her personal health number, contacts, the date of every visit, an overview of the purpose of the visit, and copies of consultations, diagnostic tests, operative reports and all other information created by the patient-physician interaction.

Physicians are obligated to keep thorough records for every patient they see. Every time a patient sees a physician, the physician is expected to record all of the details of the presenting complaint and what she/he has learned from the examination. The file should also contain a record of any diagnostic speculations or conclusions, recommended procedures or treatments, prescribed medications, and correspondence or findings from third party investigations.

 

Who owns a patient's medical record?

The actual documents contained in a patient's medical record are owned by the physician who created, received or requested them – not the patient; however, a photocopy of the content of the record must be provided to a patient upon his/her request.

 

Can patients request a personal copy of the information contained in their medical record?

A full copy of the content of the medical record is available to a patient upon written request, with some rare exceptions. Specifically, a physician is not obliged to provide information that carries the risk of causing substantial harm to the patient or another individual. The physician may also choose not to provide copies of reports that were carried out as a third party assessment of a patient's medical condition - i.e. an independent medical assessment associated with WorksafeBC, ICBC, pension groups, or an insurance company. The patient can, however, request copies of this information directly from the third party assessor.

 

Is there a cost associated with obtaining a personal copy of the information contained in a patient's medical record?

In most cases, a reasonable administrative fee will likely apply to cover photocopying costs, courier, staff time, etc. The physician should provide an estimate of the copying fees in advance. (While Doctors of BC has provided fee guidelines, payment of fees is a matter between a physician and the patient.) If the record is requested by the patient for personal use, the physician is entitled to collect the fee prior to providing the copy. Thirty days is considered a reasonable timeframe for providing the copies.

 

How does a medical record get transferred between physicians?

When a patient leaves his/her physician, for whatever reason, s/he can request in writing that the former physician provide a copy of the medical record to the succeeding physician in a timely manner – generally within 30 working days from the date of the request, or sooner if circumstances demand. The information contained in the record may be provided in the form of selected copies of relevant documentation, and/or an adequately comprehensive written summary of the patient's care. The transferred information must be sufficient enough to ensure that the succeeding physician can offer informed continuity of care to the patient.

 

Is there a cost to having a medical record transferred?

Providing copies of relevant information contained in a medical record and/or forwarding a file to another physician is a non-insured service, i.e. it is not covered by the Medical Services Plan (MSP), which means that the former physician may charge his/her patients a reasonable administration fee for either copying or summarizing the documentation contained within the file. In requesting this fee, a physician is expected to be mindful of the patient's ability to pay the administration fee.

Note: Transferring of information cannot be contingent on getting the fee. To ensure continuity of care, a physician can only ask for the fee once the transfer has been made.

 

How much does it cost to have a medical record transferred?

Doctors of BC and the Medical Services Plan (MSP) establish the guidelines for all medical-related billing. The suggested fees for non-insured services such as transferring a medical record are set by Doctors of BC alone. Costs depend on the complexity and size of the medical record.

 

Can information contained in a medical record be transferred to an alternative health provider, i.e. a naturopath or chiropractor?

Information contained within a medical record is considered to be confidential between the treating physician(s) and a patient. If a patient would like certain information contained within the record to be transferred to an alternative care provider, s/he must provide a written request to the physician – and the relevant documentation should be copied and given directly to the patient. The patient should then assume responsibility for distributing the information to his/her chosen alternative care providers.

 

Is a third party entitled to access information contained in a medical record without express patient consent?

In some circumstances, yes. For instance, if a patient has an ICBC claim, physicians are legally obliged to provide certain information to ICBC with or without the patient's consent. Patients should inquire about the type of information the third party will require prior to filing a claim. If there is information contained within a medical record that is confidential or sensitive, and deemed irrelevant to the third party claim, a patient can specifically request withholding that information from the third party.

 

How long is a physician required to keep a patient's medical record?

In accordance with legislation and other factors, a physician must retain an adult patient’s medical record for at least 16 years from the date of the last entry in the record. A minor’s record (i.e. a person under the age of 19) must be kept until s/he is 19 years old (considered an adult) plus 16 years – i.e. to age 35 – regardless of the degree of interaction between the physician and the minor.

 

Can more than one physician view a patient's medical record?

When more than one physician is providing care to a single patient, it is assumed that information regarding the care and treatment of that patient is shared between them. The implicit patient consent allows two or more physicians to transfer relevant medical information that includes documents arising from consultations with laboratory and radiology professionals, and/or from the services of rehabilitation, mental health, social work, nursing and dietary practitioners, as well as other regulated healthcare professionals.