To ensure total patient safety, streamlined oversight and the highest quality of care, Canada's government has certain medical records retention requirements that you must follow. As with any government regulations, completely learning these requirements can be a convoluted process. To help your medical organization to get on track with the federal government's medical records retention requirements ASAP, we are going to break down what you need to know about them.
Specific steps that you must take when sharing medical records
As you well know, patient privacy is extremely important. To that end, the government has made this privacy a critical element to their requirements for medical records retention. This begins with how you share patient medical records.
It is strongly recommended that you don't let the original copies of patient medical records out of your organization's control. Instead, you should provide medical record copies or summaries unless it is absolutely necessary to share the original copy. Also, make sure that you have the patient's consent before sharing any of their medical records.
Specific steps that you must take for optimal medial record security
In order to prevent a breach of the patient's privacy or destruction of their medical records, you need to add some layers of security. This rule applies whether you are using physical or digital medical records. For example, physical medical records should always be under lock and key. Digital medical records must be password protected on a secure system. Both types of records must have restricted access.
Specific steps that you must take for managing access to medical records
Although restricted document access is a mandate for your medical records retention practices, this does not mean that you get to fully dictate who has access to the medical records. Although the medical records are technically the physician’s property, the patient is still entitled to receive copies of all of their medical records from you – including those created by you and those sent to you from another medical professional.
However, there is an exception to this rule: if you have a compelling reason to refuse medical record access to the patient, then you may do so (your reason must be strong and you need to be able to prove it).
You may only share medical records with someone other than the patient if you have written consent from the patient, their legal representative, or a court – unless an entity is entitled by law to access them.
Specific steps that you must take when destroying medical records
When the required retention period for a set of medical records has expired, you may destroy them. This should be done in a thorough manner that leaves no possibility of the medical records being reconstructed.
Following all medical records retention requirements doesn't have to be overwhelming
Keeping up with the government's medical records retention requirements is easy if you have the right tools in place to help you. To that end, here is what you should do:
Use digital medical records
This allows for more security and better document access control. Also, you will always retain the original copy of the medical records, so this is never in question.
Prepare all of the consent forms that you need beforehand
By having all consent forms prepared (and possibly signed) before you ever need to share a patient's medical records, you can save yourself and the patient a great deal of difficulty.
Start preparing for Canada's medical records retention requirements ASAP
Now that you have a better understanding of the government's requirements for medical records retention, you can manage yours in a more effective manner.