Policy on medical record keeping

Retaining and transferring medical records

Generally speaking, physicians should always keep the original medical record themselves. Only copies of the record should be transferred to others.

Retaining medical records

Physicians should keep medical records for a certain period of time. For adult patients, records should be retained for a minimum of 10 years from the date of the last entry in the record. For patients who are children, physicians should keep the record until 10 years after the day on which the patient reached or would have reached the age of 19 years (the age of majority in Nova Scotia). Physicians requiring more information in this regard are encouraged to contact the CMPA.

Physician relocates

Physicians relocating their practice may opt to take the medical records with them, or leave the records with a designated physician. Where the physician elects to relocate and keep the records, or transfers the files to another physician, the original physician should notify affected patients as soon as possible after the relocation or transfer has occurred.

Physician ceases practice

The College recommends that the physician closing the practice or those responsible for closing it act in the patients' best interests by ensuring that patients have access to their records.

When physicians cease to practice medicine, two options are available with respect to patient records. The medical records may be transferred to another physician at the same address and phone number or they may be retained (either personally or through the use of a commercial record storage company).

Before patient records are transferred to a physician's successor, the physician or the physician's representative should make a reasonable effort to give notice to patients, or where this is not reasonably possible, the physician or the physician's representative should notify patients as soon as possible after the transfer has occurred.

If the medical records pertain to family medicine or primary care, where a physician is not transferring records to another physician at the same location, the physician or the physician's representative should inform patients that records can be transferred to another physician or collected in person (within a reasonable time), or the means by which records can be retrieved from storage at a later date.

Physicians should also provide the College of Physicians and Surgeons the location of their stored records and the means by which former patients can access them. Notification of patients may take place by way of a notice in the newspaper, direct communication with each patient, or in some other way that ensures that patients will receive notice.

While the obligation to retain records when the physician ceases practice continues for only two years, the College recommends that, where possible, every effort should be made to ensure all patient records are transferred or remain available to patients until they find another physician.