How Long Do You Have to Keep Medical Records?

Keeping Medical Records for a Malpractice Claim | Klein Lawyers

Physicians and healthcare professionals are legally required to document and maintain accurate, comprehensive medical records in order to provide patients with the best possible care. Medical records document many important aspects of a patient’s health and medical history, including test results, plan of care, medications prescribed, treatments performed, and much more.

Given the information in these records, it is easy to see why medical records are a cornerstone in any medical malpractice claim.

But how long should you hold onto your medical records? And how long will doctors, hospitals, and other providers keep your records on file?

How Long Should Personal Medical Records Be Kept?

Some medical records should be kept indefinitely, such as those related to major surgery or the birth of a child. For other types of care, it is beneficial to keep medical records on hand in case some type of problem arises – up to and including injury as a result of a doctor’s malpractice.

As a general rule, patients should keep their medical records for the duration of the period in which they can bring legal action against a medical provider. At minimum, this means you should keep medical records for at least two years after the treatment that you believe resulted in your injury. (Two years is the basic limitation period in British Columbia for injury claims, including medical malpractice.)

However, medical malpractice claims are unique in that patients do not always discover the injury until many years after a healthcare provider’s error. As a result, the time limit for medical malpractice claims may be extended past the basic limitation period – up to 15 years after the date that the patient suffered injury due to a medical error.

Therefore, patients should keep all medical records for at least 15 years. Parents should do the same with their children’s medical records, as malpractice claims can in some cases be brought within 15 years of the child’s 19th birthday if a medical injury occurred when the child was underage.

How Long Will Doctors Keep Medical Records?

The College of Physicians and Surgeons of British Columbia requires doctors to retain patient medical records for a minimum of 16 years from whichever of these dates comes first:

  1. The patient’s last visit to the practice
  2. The date the patient reaches the age of majority (19 years old)

Doctors in British Columbia must also meet additional requirements in their record keeping, including:

  • Patient medical records must be kept in English
  • Clinical patient records must include the following:
    • “[T]he patient’s name, gender, personal health number, date of birth, address and dates of attendance”
    • Details of the patient’s complaint
    • Tests ordered by the doctor
    • A diagnosis or provisional diagnosis
    • A “clear record of the specifics of any treatment, recommendation, medication and follow-up plan”
  • The “date of the service rendered, type of service and charge made”
  • Physical records must be “typed or legibly written in ink and filed in suitable systematic permanent form such as books, binders, files, cards or folders”
  • Electronic records must meet standards for “creation, maintenance, security, disposition and recovery”

As noted by the Canadian Medical Protective Association (CMPA), the principal reason physicians should maintain patient records for this length of time and according to these rules is to defend themselves if they are sued for malpractice. However, this record keeping is beneficial for patients as well.

Medical records are the property of the doctor, healthcare professional, hospital, or whoever created the record. However, the information inside the medical record belongs to the patient.

Patients have the right “to examine and receive a copy of the complete medical records compiled by the physician in administering advice or treatment to the patient, including records prepared by other doctors that the physician may have received.” In addition to developing a full understanding of their health, exercising the right to access medical records is crucial for patients who have suffered injury as a result of malpractice to develop a claim.

How Long Do Hospitals Keep Medical Records?

Doctors and hospitals are bound by different laws when it comes to the retention of patient health records. Time limits begin on the date that the patient is discharged from receiving inpatient or outpatient care at the hospital.

The Hospital Act Regulation in British Columbia establishes the following retention requirements for different types of records maintained by hospitals:

1. Primary Documents

Primary documents must be kept for a minimum of 10 years. A primary document includes:

  • “pertinent health care data of a patient’s health record including case histories, discharge summaries, consultation reports, day care records and other documents prepared or signed by an attending practitioner or, as the case may be, practitioners”
  • “reports regarding significant findings, items or comments, initially recorded in a secondary or transitory document, that have been transferred to and recorded on a primary document”

2. Secondary Documents

Secondary documents must be kept for a minimum of six years. A secondary document is defined as:

A “document that contains information about a patient that may be of vital medical importance at a particular time and may have lasting legal significance but is not considered necessary for care and treatment of the patient beyond that particular time, and includes any diagnostic report, authorization, out-patient record, adverse event report … and nursing report or note”

3. Transitory Documents

Transitory documents must be kept for a minimum of one year. A transitory document “appears to have no medical importance or lasting legal significance once a patient has been discharged from a hospital, and includes a diet report, graphic chart or departmental checklist.”

How Do I Obtain a Copy of My Medical Records?

Getting a copy of your medical records should be as simple as asking your doctor to see the records or contacting the hospital records department. The provider may charge you a small fee to make copies, but otherwise you should have no problem getting access to the information.

However, sometimes patients are refused when they ask to inspect their medical records or receive copies. Providers may argue that disclosure of certain medical information may result in harm to the patient’s physical or mental health, or that the information falls outside of the doctor-patient relationship (such as reports from other physicians).

In the landmark case of McInerney v. MacDonald, the Supreme Court of Canada ruled that “The onus is on the physician to justify a denial of access.” As such, patients have the right to dispute a doctor’s reasoning for denying access to their medical records.

If a doctor or hospital refuses to let you see your medical records, this could indicate wrongdoing on the part of the provider. You should seek legal help immediately.

Why Medical Records Are Important

Medical records are important because they help physicians and healthcare providers provide patients with better, more accurate care. Knowledge of previous illnesses and injuries, prior treatments, and current and former medications – among other information – can help doctors and other providers care for patients more effectively.

Other important aspects of medical records include:

  • Documentation of Medical History: Complete medical records document the state of your health over time. If you suffer a medical injury, thorough evaluation of your records can reveal how and when a physician error occurred and how it has affected your health.
  • Record of Billing: Insurance will not cover all of the expenses related to treatment of a serious injury or illness. Billing records from the doctor’s offices, hospitals, and other facilities where you receive care can help establish the economic damages associated with a medical injury.
  • Establishing the Doctor-Patient Relationship: A number of different medical professionals may be liable for malpractice. However, the success of your claim rests on your ability to prove that the negligent provider(s) owed you a duty of care. Your medical records will show who treated you, when, and for what. In conjunction with the details of treatment included in the medical records, this information can establish the liability of a medical provider for your injuries and damages.

In the event of a medical error, accurate records are essential for proving a claim of malpractice. Unfortunately, accurate record keeping on the part of a provider is not guaranteed. In the most egregious circumstances, providers and practices may even alter patient records in an effort to erase evidence of their mistakes.

An experienced lawyer can review your medical records and investigate all aspects of the care you received. Expert witnesses are often involved in this process as well, providing authoritative insights on medical treatment and what the evidence says about potential malpractice.

Get Started on Your Medical Malpractice Claim

Medical records are complicated. The majority of patients are unfamiliar with the terms doctors use in these documents, making it difficult to identify potential errors on your own.

Klein Lawyers has the knowledge and resources to help you navigate the complexities of a medical malpractice claim. Our team thoroughly gathers medical records and other evidence in your case, builds a strong claim on your behalf, and pursues the fair compensation you deserve.

Due to the aggressive defence mounted by healthcare providers and hospitals, insurance companies, and the CMPA (which represents physicians facing claims of malpractice), medical negligence cases often go to trial. It is essential to hire an experienced trial lawyer who can seek a favourable result via settlement or court judgment.

Please contact Klein Lawyers at (604) 874-7171 today for a free evaluation of your medical malpractice claim. Our lawyers serve clients in Vancouver and throughout British Columbia, including the communities of Abbotsford, Burnaby, Coquitlam, Langley, and Surrey.