PHIPA and Health Information Custodians
When an occupational therapist is working privately, either in their own practice or contracting their services, they are accountable for documenting and maintaining their own clinical records. The occupational therapist should follow the expectations outlined in the Standards for Record Keeping, including taking steps to determine if they are the health information custodian (HIC) or the agent of the health information custodian (agent). The
Personal Health Information Protection Act, 2004 (PHIPA) specifies who can and who cannot assume this role. An occupational therapist in private practice could be a HIC; however, if an occupational therapist is subcontracting their services through another agency, they may be acting as an agent of the HIC. Occupational therapists who are HICs should establish privacy policies that are consistent with relevant privacy legislation such as PHIPA.
It is the responsibility of the occupational therapist to determine if other privacy legislation applies to their private practice and to follow what is outlined in the applicable legislation.
Retention of Clinical Records
Occupational therapists in private practice must determine if they are acting as the health information custodian (HIC) or the agent, which determines responsibility for retention of records. The expectations for retention of clinical records are outlined in the Standards for Record Keeping. Occupational therapists retaining clinical records privately, such as in their home, clinic, or office, should take reasonable measures to ensure the safety and security of those records as outlined in the Standards for Record Keeping and PHIPA or other relevant privacy legislation.
Succession Planning for Clinical Records
Occupational therapists in private practice should seek legal advice to establish an estate plan to ensure that clinical records are securely maintained and retained in the event of an unforeseen event, such as the death of the occupational therapist. This is referred to as succession planning.
2
Record Keeping Practices When Providing Non-Clinical Consultations
Occupational therapists who are providing non-clinical consultations need to determine the most appropriate method of record keeping. This may include maintaining records consisting of the date the consultation was provided, to whom it was provided, and the recommendations that were provided. Occupational therapists should use their judgement to determine how relevant information pertaining to the consultation should be documented and maintained.
2 Information and Privacy Commissioner of Ontario, April 2019. Retrieved from https://www.ipc.on.ca/wp-content/uploads/2019/04/fs-health-abandoned_rec.pdf.