Clinical records

This page provides information about legislation guiding the collection of personal information for MSP and outlines the requirements of adequate clinical records.

Personal information  provided to MSP is collected under the authority of the Medicare Protection Act and is used to determine B.C. residents’ eligibility for Ministry of Health programs. This information is protected and accessible under the Freedom of Information and Protection of Privacy Act.

Information submitted by health care practitioners related to the clinical care of an MSP beneficiary is likewise collected under the authority of the Medicare Protection Act.

Adequacy of clinical records

RN(C)s, RPN(C)s, RNs and RPNs are required to maintain adequate clinical records according to the standards of practice set by BCCNM.

Clinical records must support the information submitted to MSP for all requests for diagnostic tests. An adequate medical record, as outlined in the Medical Services Commission Payment Schedule Preamble (PDF, 180KB) includes: 

1. Date and location of the service;
2. Identification of the patient and the attending practitioner;
3. Presenting complaint(s) and presenting symptoms and signs, including their history;
4. All pertinent previous history including family history;
5. The relevant results, both negative and positive, of a systematic enquiry pertinent to the patient’s problem(s);
6. Identification of the extent of the physical examination including pertinent positive and negative findings;
7. Results of any investigations carried out during the encounter; and
8. Summation of the problem and plan of management.

Records retention

Under the Medicare Protection Act, a practitioner must retain medical/clinical records for a period specified by the appropriate licensing body or, if the appropriate licensing body has not specified a period, for a period the commission specifies.

Release of MSP data

MSP maintains personal data and claims records for the life history of an individual.

Individuals may request a copy of their personal data and claims records from MSP under the Freedom of Information and Protection of Privacy Act. 

MSP will release personal data and medical claims records to a third party only if the following conditions are met:

• the third party submits a written request for the records; and
• MSP is satisfied that the request is appropriate; and 
• the release is authorized and accompanied by an authorization or consent form signed by the beneficiary whose records have been requested.

Access to clinical records

In June 1992, the Supreme Court of Canada made a judgment regarding office medical records. While recognizing the practitioner’s ownership of the clinical records, the case judgment states that the information in those records belongs to the patient and that the patient has a right to access that information upon request.

The ruling means that patients have the right to read and copy the information contained in their medical files, including material in the files from other practitioners but excluding medical legal correspondence and independent medical examinations. It is advisable to provide the requesting patient with photocopies of the medical record to ensure that the original office medical record remains intact.

The practitioner may refuse the patient access to the office medical record if it is the practitioner’s judgement that the information may cause harm to the patient or to an innocent third party. 

All nurses are advised to become familiar with the freedom of information and protection of privacy policies of the health authorities or agency in which they are employed.