The following are commonly asked questions of the Practice Advisor regarding the retention and transfer of patient records.
1. I'm an associate at a clinic and am leaving to start my own practice. Can I take the original patient files?
Only if there's a written agreement, between the associate and the clinic owner, stating that the associate is the designated owner of the specified patient records. If a written agreement states that the clinic is the designated owner of original patient records, you can't take those files. (Please note that the College doesn't provide legal advice; consult a lawyer before entering or executing any contracts or agreements.)
2. What if there's no agreement with the clinic owner on who owns the files? Who is entitled to them?
Either party can become the designated owner of patient records. It's the responsibility of all parties to act professionally, and to come to an agreement to ensure records are transferred and retained according to the Standard of Practice for Record Keeping.
It's prudent to ensure the agreement is in writing, and deals specifically with the rights and obligations of each party upon termination of the arrangement. When a practice arrangement between two or more health care practitioners ends, each practitioner is responsible for ensuring that disputes between them do not affect patient care. Therefore, the contract should not:
- provide any terms that would in any way prejudice the future treatment of patients;
- limit the access of the patient to their naturopathic medical records; or
- restrict patients' right to choose - while the original patient record remains in one location, the patient can pick their naturopathic doctor.
3. What are my obligations when the original files remain at the practice I'm leaving?
You're required to send a notification to patients of a change of address, where their file is located and how they can access it. ND's must also notify the College within 30 days of the change of address.
4. If I'm taking original patient files with me can the previous clinic keep a copy?
Only if the patient consents.
5. What happens if an insurance company requests information about a patient?
An ND must obtain express consent from the patient, or their authorized representative, to provide patient information to anyone else. There are some exceptions to sharing information without consent: when it's required by law, including requests from the regulatory college; when there's a risk of harm to the patient or others; or when another health professional is within the circle of care. Be aware that the insurance company will likely accompany their request with the patient's consent. If the insurance company does not include the consent, you should remind the insurance company that it is required. This will ensure that you are disclosing patient information with the requisite authority.
6. In relation to a complaint, the College has requested the original file of a patient. My previous location has retained the original. What do I do?
It's your obligation to have the current address and contact information of your previous practice location, and to obtain the original copy for the College. The original will be returned to the owner of the file once the College has completed the complaint process.
7. How long do the original files need to be retained?
- For adult patients: at least 10 years after the date of the last entry.
- For patients younger than 18: at least 10 years following the patient's 18th birthday, regardless of the date of the last entry.
8. What do I do with the files after 10 years?
Either keep storing them or destroy them. If destroying the records, do so by shredding, burning, using overwriting software, or some other method to render them illegible and irretrievable. Retain a record of disposal dates and the names of the patients whose records were disposed.
Standard of Practice for Record Keeping
Standard of Practice for Consent
Informed Consent Guideline