Case of the Month
The Case
The College received a call from a patient who tried to get a copy of their patient record from a physiotherapist they had seen seven years ago. Unfortunately, the clinic that the patient attended had since closed, and the patient had no way of contacting the physiotherapist.
As the Health Information Custodian (HIC), the physiotherapist was required to keep the patient’s records for at least 10 years after the patient’s last appointment.
The College offered to contact the physiotherapist who resigned their registration in 2016. In their response, the former registrant said they were unable to provide a copy of the patient’s record because it had been destroyed.
The former registrant confirmed that they closed their clinic in 2015 and moved out of the country. They indicated that all patient records were kept in their previous home in Ontario, where their spouse was still living up until 2020.
The couple separated in 2020, and the former registrant’s spouse decided to sell their previously shared home and move to another city. The former registrant was still living outside of the country and was unable to retrieve the patient records due to COVID-19 border restrictions.
Although the former registrant maintained that the records were safely stored at their previous residence, they were unable to find any other options to securely store the records after their spouse moved. As a result, the former registrant hired a private company to destroy the records to avoid any issues with confidentiality.
The former registrant did not consult the College or review their professional obligations before having the records destroyed.
The Standards
Physiotherapists and former registrants of the College have legal and professional obligations to retain patient records and make sure patient records are maintained and stored in an appropriate way.
According to the Record Keeping Standard, physiotherapists are required to keep clinical and financial records for at least 10 years from the later of the following two dates:
- The date of the last patient encounter, or
- The date that the patient reached or would have reached 18 years of age.
Physiotherapists must be able to retrieve and reproduce a complete clinical and financial record for each patient throughout the full retention period. In this case, the former registrant destroyed the patient’s records before the 10-year retention period was over.
When a physiotherapist closes a clinic, they will usually find another physiotherapist to become the Health Information Custodian (HIC) for the patient records associated with that clinic. HICs have certain responsibilities as outlined in the Personal Health Information Protection Act (PHIPA), like making sure patients know who has control of their personal health information.
Additionally, physiotherapists are required to report unlawful or accidental destruction of patient records to the Information and Privacy Commissioner of Ontario (IPC) .
In this case, the former registrant did not meet their professional obligations as a physiotherapist and HIC, they did not consult the College before destroying the patient records, and they did not make a report to the IPC.
Finally, although the individual was no longer registered with the College, it’s important to note that as outlined in the Regulated Health Professions Act, the College maintains jurisdiction over former registrants if the events in question occurred when the person was registered with the College.
The Outcome
The Committee decided that the concerns were significant enough to require the former registrant to receive a caution. A caution stays on the Public Register permanently.
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