Patient Record Retention

Morgan Hrynyk Are You Up to Standard?, Messenger, Standards 2 Comments

The new Patient Record Retention standard addresses the responsibilities of regulated members for the collection, use, disclosure and protection of health information. Most importantly, the standard identifies that a regulated member is responsible for following the rules established in the Health Information Act (HIA).

The principles of the new standard are unchanged from the previous Patient Records standard. New to the standard is the expectation that physicians name a successor custodian.

  • Having a successor custodian will ensure patient records are appropriately protected and accessible even in rare circumstances where a physician is unable (or fails) to do so him/herself. For example, a physician could die suddenly or within the 10-year period his/her patient records must be retained by law, or move to another jurisdiction and abandon his/her patient records without making appropriate arrangements (in breach of the standard).
  • A successor custodian may be an eligible entity, colleague or other healthcare professional, as designated in the Health Information Regulation.  
  • A successor custodian must be willing to fulfil this role, and can be named through an agreement or as part of a clinic’s policies and procedures.

Some physicians may choose to make arrangements with a records management company to store their patient records. In this case, a successor custodian must still be named to fulfil the duties and powers of custodians identified in Part 6 of the HIA. The HIA Guidelines and Practice Manual is a good resource for additional information.

Stay tuned! In upcoming issues of The Messenger, we will explore other aspects of Patient Record Retentionand Patient Record Content, to help you stay up to standard!

Questions or comments? Join the conversation below!

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Andrea

How long after a patient passes away do we have to keep records? Paper or otherwise.

Hi Andrea,

Thanks for reaching out. Our standard of practice around patient record retention states that all records must be retained and accessible for a minimum of 10 years from the date of last record entry for adult and minor patients, or two years after a minor patient reaches or would have reached the age of 18, whichever is longer.

For more information, our standard of practice is a great resource: http://www.cpsa.ca/standardspractice/patient-record-retent/

If you have any other questions, please feel free to send us an email at info@cpsa.ab.ca.

Thank you!