Record Keeping

A manual osteopath shall keep a daily appointment record, financial record and patient health record. All records shall be accurate, legible and comprehensive.

• The daily appointment record shall set out the surname and initials of each patient the member examines or treats or to whom the member renders any service.
• The financial record shall contain; date of service, services billed, payment received; and balance of account.
• The patient health record shall contain; patient’s name, address, birth date and gender, dates of each of the patient’s visits to the member, a reference identifying the patient, and the name/address of the primary treating manual osteopath, on each separate page, and name(s) of relevant referring health professionals, if appropriate.
  
  The patient health record shall contain a history of the patient, including; patient’s chief complaint(s)/concern(s) and supporting data, & relevant past health history.
• Every patient health record, including every financial record shall be retained for at least seven years following the patient’s last visit, or, if the patient was less than 18 years old at the time of his/her last visit, the day the patient became or would have become 18 years old. Destruction of patient health records shall be done in a secure fashion to ensure that the records cannot be reproduced or identified in any form.
• As part of the resignation process from active manual osteopathy practice, the manual osteopath shall take reasonable steps to ensure with regard to each patient health record for which the member has primary responsibility:
  • the record is transferred to another member and reasonable efforts are made to obtain the patient’s consent;
  • the patient is notified that the member intends to resign and the patient can obtain copies of the patient health record; and
  • if the record transferred is not the original patient health record, the original record is stored in a secure location for seven years following the patient’s last visit, or, if the patient was less than 18 years old at the time of his/her last visit, the day the patient became or would have become 18 years old.
• A manual osteopath shall not allow any person to examine a patient health record or give any information, copy or thing from a patient health record to any person except as required by law or as required or allowed by this section.
• A member with primary responsibility for a patient health record shall provide, on request, copies of or access to a patient health record to any of the following persons, or any person authorized by the following persons:
  • the patient;
  • a personal representative authorized by the patient to obtain copies from or access to the record;
  • if the patient is deceased, the patient’s legal representative;
  • if the patient lacks capacity to give an authorization, a committee of the patient appointed under the Mental Incompetency Act.
• A manual osteopath is not required to provide copies from or access to a patient health record if the member is of the opinion that disclosure of the health record would likely result in serious harm to the care of the patient or serious physical or emotional harm to the patient or another person.
• A member shall, upon receiving written authorization from the patient or a duly authorized person, provide a copy of the patient health record in a timely manner. The member shall maintain the original patient health record even if he/she is no longer providing manual osteopathy care to that patient.
• A member may charge a reasonable fee prior to providing copies of a patient health record to reflect the cost, time and effort required to provide copies of the patient health record.
• A member may provide copies of or access to a patient health record to his/her legal counsel or insurer where the patient health record is relevant to advice being sought by the member or required by the policy of insurance.
• A member may, for the purpose of providing health care or assisting in the provision of health care to a patient, allow a health professional to examine the patient health record or give a health professional any information, copy or thing from the record.
• A member may maintain an electronic record keeping system. The member shall take reasonable steps to ensure the electronic record keeping system is so designed and operated that patient health records are secure from loss, tampering, interference or unauthorized use or access.