Duties and responsibilities
Medical records: Advice about maintaining their integrity and providing them to lawyers
An article for physicians by physicians
Originally published Fall 1999 / Revised May 2008
CMPA answers your questions about documentation.
Of interest to all physicians
The CMPA receives many types of questions from members. Some are frequently asked; some are unexpected and require consultation with legal counsel. Most generate information that other members may find useful. Here, we share some of the learning from your questions.
The CMPA has been asked for advice about incorporating information from original laboratory records into a separate flow sheet that is then kept on the patient's chart as a quick overview of the patient's lab results. The question has been raised whether it is necessary to keep the original lab reports once the information is transferred to the flow sheets. The CMPA recommends that all original copies of lab results be maintained on the chart, even if the information is transferred to a secondary document. Indeed, some regulatory authorities (Colleges) explicitly require that the original report be retained.
About providing medical records to lawyers
Q: Should I send a patient's record when it is requested by a lawyer?
A: Legally you must only provide the requested records if written and dated authorization from the patient, or the patient's legal representative, accompanies the request. The authorization should specify the records that the patient consents to releasing and to whom they can be released. In that situation you must provide a copy. If there is no authorization, you should advise the lawyer that you have received the request but can't provide the record until you have the proper authorization in hand.
Q: Should I send the original or a photocopy?
A: Send a copy. Your original records belong to you and should only be released after consultation with your legal counsel and after ensuring you have kept an original copy of the complete record.
Q: Does this request mean I'll be involved in a legal action?
A: It may, but not necessarily. The lawyer is likely seeking general information about the patient's care. A legal action may follow and you may or may not be named if there is a legal action.
Q: What should I copy?
A: Clinical notes, investigation reports or results, and consultation reports. If you're in doubt—for example, about releasing copies of reports prepared for third parties such as insurance companies—members are advised to contact the CMPA prior to releasing the record.
Q: Can I charge the lawyer for photocopying?
A: Yes. You can recover reasonable photocopying and administrative expenses. Some provincial and territorial medical associations and regulatory bodies (Colleges) have guidelines you may wish to consider in determining a reasonable charge.
If the lawyer subsequently requests more information, or if you later receive any legal document, members should contact the CMPA promptly for assistance.