Medical records are powerful sources of information about a patient’s medical history, including history of treatments, medications taken, health problems or patterns, and similar.
The primary purpose of the medical record is to enable physicians to provide consistent, comprehensive, sensible and continual care to their patients. However, medical records are also legal documents that can provide evidence about the quality of care where that care is questioned.
Oftentimes patients have no idea what is written in their medical records by health providers or whether that information is accurate.
It is a good idea to be aware of what is in your medical records, even before you may have a reason to request access to those records (for instance, if you are considering filing a medical malpractice claim). Patients should be familiar with their medical history, and should ensure records are up to date and accurate. It is always better to be informed.
Who Do Medical Records Belong To?
Your medical information belongs to you. In the landmark decision in McInerney v. MacDonald, the Supreme Court of Canada found that the information in medical records belongs to the patient, but the physical record itself belongs to the organization or person responsible for its creation (in most cases, the physician or the hospital).
Almost all provincial medical associations (which regulate the practice of medicine in each province) have best practices guidelines for medical records.
Will I Always Have Access to my Medical Records?
Probably not. Generally, every province in Canada allows medical practitioners to destroy medical records after a certain period of time has transpired. For example, this is the document retention recommendations of the Canadian Medical Protective Association (CMPA), the “mutual defense association” representing doctors from across Canada:
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Retention of clinical records by physicians in Canada |
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Province/ |
Requirements/recommendations |
Age of majority |
|
|
British Columbia |
16 years from either the date of last entry or from the age of majority, whichever is later (College Bylaws pursuant to the Health Professions Act) |
19 |
|
|
Alberta |
10 years from date of last service or no less than 2 years past age of majority, whichever is longer (College Standard #21) |
18 |
|
|
Saskatchewan |
6 years; 2 years past age of majority, or 6 years after date last seen, whichever is later (CPSS Regulatory Bylaw and By-law #46 under the Medical Profession Act) |
18 |
|
|
Manitoba |
10 years from date of last entry or in case of minor, age of majority plus 10 years (By-law #1 under the Medical Act) |
18 |
|
|
Ontario |
10 years or 10 years past age of majority (Medicine Act, 1991 Regulations), or until physician ceases to practice (College recommends 15 years from date of last entry or 15 years after the day on which patient reached or would have reached age of majority) |
18 |
|
|
Québec |
5 years from date of last entry (up to 10 years for certain documents) (Medical Act Regulations) |
18 |
|
|
New Brunswick |
10 years after the patient was last seen or until age 21 (whichever is longer) (recommended by College) |
19 |
|
|
Nova Scotia |
10 years or 10 years past age of majority (recommended by College) |
19 |
|
|
Prince Edward Island |
10 years after date of last attendance or 10 years past age of majority or 10 years after member ceases practise, whichever comes first (recommended by College) |
18 |
|
|
Newfoundland & Labrador |
10 years after the patient was last seen, or in the case of a patient who was a minor when last seen, until that patient reaches age 21, or 10 years from when that patient was last seen (whichever is longer) (College Bylaw #6) |
19 |
|
|
Yukon |
6 years from date of last entry (Medical Profession Regulations) (Yukon Medical Council recommends 7 years where minor, the later of 2 years past the age of majority or 7 years since the last date seen) |
19 |
|
|
Northwest Territories |
10 years or no less than 2 years past age of majority (whichever is longer (Adoption of Alberta College Standards of Practice)) |
19 |
|
|
Nunavut |
10 years or no less than 2 years past age of majority (whichever is longer (Adoption of Alberta College Standards of Practice)) |
19 |
|
What Does This Mean for My Access Rights?
A patient has the right to see the content of their medical records (with the exception being if revealing the information will cause harm to the patient or others).
Practically, this means that you can make an appointment with your physician to request a review of the records, or you may ask for copies of the records to be provided to you. In turn, the physician or organization must provide you with access to the record (but may charge a fee for doing so). You have a right to access all of your medical information, even any that is marked confidential. Doctors and organizations are required to grant you access within a reasonable time following your request, and cannot refuse access, even if a malpractice claim has been filed against them. Doctors are also not permitted to make any changes to medical records in the event of a medical malpractice claim against them.
During our investigation, it is our usual practice to request and review copies of all relevant medical records very carefully in order to ensure that our investigation is thorough and complete.
If you have questions about the medical care provided to you or a loved one, but cannot get access to the appropriate records of treatment, then, contact the lawyers at Sommers Roth & Elmaleh in Toronto. As one of the oldest medical malpractice firms in Toronto, we are highly respected in both the medical and legal fields. We offer compassionate, knowledgeable, and skilled guidance on all aspects of medical malpractice claims. Call us at 1-844-777-7372 online for a free consultation.