Good Practice: Patient Records Shouldn't Be Difficult

One of the continuing issues we seem to get at the College of Physiotherapists of Alberta concerns patient records and the legislation that dictates how we handle them. As discussed in Good Practice: When Your Patient Wants You to Destroy Their Patient Files, we know that physiotherapy patients fall under four different categories of privacy legislation, but access to physiotherapy records can be quite simple. 

Question #1: Who owns the patient record?

The patient’s chart is kept safe and secure by the custodian therefore, they would provide “ownership” over that record. However, the patient has a legislated right to access that record and owns the contents of the record (the information in the record). If a patient requests their record, the custodian provides a copy of the record. The original copy remains under the custody and control of the custodian.

In private practice, the custodian would be the clinic or organization that the physiotherapist would be employed or contracted by, unless the contract identifies the physiotherapist as the custodian. This means that if the physiotherapist leaves a practice setting, the chart remains at that location. In most public practice settings, the facility (hospital, school, long-term care) would act as the custodian over the patient’s record. 

Question #2: What fees are charged for chart copies?

This depends on the legislation it falls under. The Health Information Act (HIA) governs hospitals and public facilities as well as the records of those involved in motor vehicle collisions treated under the Diagnostic Treatment Protocols Regulation (DTPR). You can access the HIA here:

https://www.alberta.ca/health-information-act.aspx

Those providing services to patients that fall under the HIA can charge a $25 fee for producing a copy of the chart up to 20 pages. Every page after that is charged at 0.25 cents per page.

Private practice physiotherapists are governed under the Personal Information Protection Act (PIPA), where there is no set fee structure for chart copies defined in the legislation. A “reasonable fee” can be charged to the party requesting access and an estimate must be provided to the applicant prior to the copies being provided and the party being billed. The fee structure should be the same whether the patient is paying for it, or it is getting billed to a law office representing their client. Fees should be a reasonable price that would not prohibit the patient from accessing their record and should reflect the cost of products and the workload to produce it. 

We are regulated health professionals and practice under a Code of Ethical Conduct. Maybe reframe it as to what you would feel comfortable charging your friend, colleague, or family member for their 10-page physiotherapy record? You can read the Code of Ethical Conduct to reflect on your answers here: 

Code of Ethical Conduct

Question #3: How much time do I have to produce a copy of the patient’s record?

HIA = 30 days
PIPA = 45 days

Question #4: What do I include in the chart copy?

• The Documentation and Record Keeping Standard of Practice requires that you document and retain the following information: Client’s identity (name, birth date, unique identifier) on each discrete part (each page) of the client record.
• Client’s reason for attendance.
• Client’s relevant health, family, and social history.
• Dates of each treatment session or professional interaction, including missed or cancelled appointments, telephone or electronic contact.
• Assessment findings.
• Treatment plan and goals.
• Details of treatment provided and patient response to treatment, including results of reassessments.
• Details of all client education, advice provided and communication with or regarding the patient.

Reports from specialists, email chains to the patient pertaining to patient care, diagnostic imaging, etc. are all part of the official record and should be included if you have received a request for a complete chart copy. 

We have hopefully covered the basics so let’s get into the scenarios so we can test your knowledge!

Scenario #1:

Patient A gets into a motor vehicle collision and is being treated as a WAD II and agrees to be treated under the DTPR. They come to the clinic halfway through the 90-day treatment window and present you with a signed consent form from their lawyer asking for a chart copy to be sent to their office. Their chart is 22 pages and includes your notes, as well as diagnostic imaging.

How much time do you have to process the request and send the info? This falls under the HIA since it is in the DTPR, therefore you have 30 days.  

How much can you charge them for the chart copy? 22 pages under the HIA is $25 + 2 pages at 0.25 cents each so $25.50 is the total fee that should be billed to the lawyer for executing this action. 

Do you need to include the diagnostic imaging? Yes, the chart copy should be complete, this means everything you have in your chart counts. This includes, correspondence, diagnostics imaging, etc. 

What if the patient wasn’t a WAD II and instead had a pelvic fracture? The patient would then choose to be treated outside of the DTPR and would then fall under PIPA. In that case, all access to information is driven by patient consent. 

What if the lawyer contacted you directly? You'd need to make sure you had consent from the patient to release the chart. 

What if the lawyer failed to include the patients consent in the request? If they failed to provide documentation of consent to release the chart to the lawyer, then you need to obtain it before you release the record.

Scenario #2:

Patient B is employed by a school district in rural Alberta. They have many patient families that they must communicate with through the school. A family is moving across country and would like a copy of their chart to take with them to their new school since their youngest will continue with physiotherapy services there. 

What legislation is involved in schools? Freedom of Information Protection (FOIP) applies to the records generated by school employees and retained by schools. Similar to PIPA, there isn’t a structured fee for this access but again the term “reasonable” is used and it shouldn’t present a barrier for patients to access their information. It is important to remember any charts involving a minor must be kept for 10 years after they turn 18. 

What if one of the teachers wanted to provide the child’s physiotherapy assessment to another staff member involved in the child’s care? FOIP would indicate that this would be utilization of the information for its intended purpose. The teacher is directly involved in the child’s care and the information would allow the second teacher to implement the care plan. 

Scenario #3:

Patient C has been attending your private clinic for the past 2 months after a shoulder dislocation. They just found out they are being transferred to the West Coast and are getting ready for the move. They want your clinic to forward their record to the new clinic. 

What legislation applies? PIPA would apply in this scenario as it is based in a private practice setting. 

Can you email the patient’s record since its all electronic, or do you still need to send it via fax machine? I know it seems crazy that in the digital era fax is still considered one of the more secure ways to send chart copies, but you can choose to use electronic forms of communication. According to the Office of the Privacy Commissioner the “HIA requires that custodians take reasonable steps to maintain safeguards to protect the confidentiality of health information and to protect against any threats to the security of health information, to the loss of health information, and to any potential breaches of health information”

And more specifically in regard to encryption “Diagnostic, treatment and care information should be encrypted. A message itself, attachments or a combination of these may require encryption. If mobile devices are used to store health information, those devices must be encrypted.” So, the record should be encrypted while in storage and while being transmitted from one clinic to another.

There is much more information to be found here: 

https://www.oipc.ab.ca/media/1001934/Advisory_Electronic_Patient_Communication_Jun2019.pdf

Conclusion

Chart copies and access can follow a pretty standard picture. It is paramount that we maintain privacy according to the Privacy Standard of Practice and applicable legislation, details of which can be found in our Privacy Guide here: 

Privacy Guide

In summary, if a patient asks for a copy of their patient record you would: 

1. Include everything in their patient record
2. Charge them the fees set out in HIA or something that is reasonable to cover the cost of creating the record
3. Do it in a reasonable time frame but 30 days for most legislation and 45 days for PIPA
4. Remember it is their patient record and they do have legal right to access to it, and it shouldn’t be a hassle.

If you have any questions around chart copies that you would like answered please contact me and I would be happy to answer them for you.

Page updated: 06/06/2023