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January 2019: How long should I keep client records?

Q: If I am a health information custodian, how long should I keep a client's records?

A: The Personal Health Information Protection Act, 2004, (PHIPA), s. (3), set outs the definition, responsibilities and rules for health information custodians (HICs) handling personal health information. 

Clinical records must be retained for at least 10 years from the date of the last entry in the record or the date 10 years after the day on which the client reached or would have become 18 years old. 

Records are maintained after the 10-year period if it is reasonably known that health information will be required for a valid reason, for example, notification of pending legal proceeding.

In circumstances where the client is deceased, the record should be retained for the full retention period.

Q: What is the College requirement for disposal of client records after the retention period?

A: Client records should be destroyed in a secure manner, both in electronic form and paper, to prevent anyone from accessing, discovering or otherwise obtaining the information.

If an OT is a health information custodian, they should maintain a list of names and dates for those files that have been destroyed. For example: name of the client, file or unique identifier, date file was destroyed or deleted.  This list should be maintained until it is no longer reasonably necessary according to the OT’s practice policy.

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