Doctors in New Brunswick are required by their professional body and by the law to create records of the medical care they provide you. For most people in most cases, this means they record your basic information like address and date of birth; when they saw you as a patient; any assessment and diagnosis they made at the time; and a record of treatments prescribed or administered. They also are to be stored safely and must be legible. (For more information, visit the professional regulating body for doctors, the College of Physicians and Surgeons of New Brunswick).
Your doctor also has to keep this record for a considerable period of time after you reach the age of majority. In fact, doctors can be required to keep records on your care for a period even after you die. If your record is stolen or lost, your doctor must inform you of the potential for disclosure of your information. If your doctor reasonably believes there will be no disclosure of your information and no adverse impact on you, the notification is not necessary.
In some cases, your medical record is also maintained by the Province. Similar to accessing your record from a hospital stay, some doctors who work for the Province have their records maintained by professional staff. Access to those records follows a similar procedure, but you don’t have to go through the doctor who treated you.
Physicians in New Brunswick are subject to the Personal Health Information Protection and Access Act (PHIPAA). The Act specifies the way in which you can get access to your record.
Within 30 days of a request from you to your doctor, they must make any record accessible for your inspection. This should be done without a charge, though if you want help in understanding your record, the physician may bill you for such assistance. The patient may request the assistance of the physician in interpreting the record.
If you want a copy of your record, you also can receive that within 30 days of a request. Your doctor may, and usually will, charge you for the costs they incur in photocopying the record and mailing it to you (or the equivalents). There are some exceptional circumstances where you might be charged for retrieving the record.
Your doctor may decline to provide information from your record under a select number of circumstances, the most common of which would be where the disclosure would cause harm to the patient or another. If your doctor declines to disclose certain information, they should make an effort to sever such from the rest of the record which can be disclosed.
In most cases, the Act does not entitle a patient to a translation of the record into their preferred language. The only exception is the obligation of a Regional Health Authority to translate a record if a patient is under the care of a physician who does not understand the language in which the record was prepared.
The Act does clarify the right of access to patients’ records for family members of patients who become incompetent, as well as following the death of the patient.
Patients may request “corrections” to their records. If the physician agrees, this would normally be done as an addendum, making clear that an original record has been modified. If the physician objects, there is an obligation to note the objection and for such to become a part of the record.
Transfer of relevant information among physicians, and others directly involved in the patient’s care, must always be expedited in the patient’s best interest. In the normal course of health care delivery, such should occur without the need for express consent from the patient or their personal representative.
Where information is transferred to any other party, or for any other reason, such should be done with a clear express consent of the patient or another person entitled to act in their stead, according to the provisions of PHIPAA.
When a physician’s practice closes due to retirement, relocation, or death, the storage and distribution of records can represent significant challenges. Patients in active treatment should be given notice of the location of their records for the purpose of eventual access.
Most of the time, physicians who retire either store their records electronically or use a document storage agency (usually specifically designed for such storage).
For any questions on accessing your medical record, you should first consult your doctor. For other information, inquire with the College of Physicians and Surgeons of New Brunswick.
The information on this page of the website has been adapted from information provided by the College of Physicians and Surgeons and the Province of New Brunswick.