Releasing Patient Records
Members sometimes contact PLP for advice on responding to patients’ requests to obtain their records or to have them sent to third parties. The following are key considerations in deciding how to react to such requests.
Does the dental record belong to me or my patient?
While the information in a health record belongs to the patient, the physical record belongs to the practitioner who created it. Therefore, on request, members have an obligation to provide patients with high quality copies of the contents of their charts, including radiographs, progress notes and any other information forming part of the clinical record. They cannot insist on forwarding the information only to another dentist or health professional and dentists should not release original records, radiographs, etc. to patients or third parties except as required or authorized by law.
Read more: Duty of Dentists to Share Original Records during Coroner’s Investigations
Who can consent to the release of dental records?
In Ontario, capable persons have the right to access and to request or refuse disclosure of their health records to a third party. A person is capable if he or she can understand the information relevant to making a decision about and appreciates the reasonably foreseeable consequences of giving, withholding or withdrawing consent. There is no minimum age of consent and any patient aged 16 or older is presumed to be capable of giving consent in the absence of reasonable evidence to the contrary (e.g. immaturity, intoxication, dementia, etc.). Consent for the release of records of an incapable patient must be obtained from a substitute decision maker.
Read more: Children and Consent to Treatment
Who can consent to the release of dental records of a deceased patient?
Unless otherwise authorized or required by law, consent for disclosure of a deceased patient’s personal health information must be obtained from the patient’s personal representative (estate trustee or administrator or, if the deceased was a minor child, his or her parent or guardian).
Read more: Release of Patient Information of Deceased or Missing Patients
Is express consent always required to release a patient’s health records to a third party?
Except as required or permitted by law, express verbal or written authorization is needed in order to disclose a capable person’s records to anyone outside the patient’s “circle of care”, i.e. health professionals involved in specific treatment. Even a patient’s other health care providers, new dentist, family members and lawyer are not entitled to receive personal health information about the patient without the patient’s consent.
Read more: Circle of Care, Sharing Personal Health Information for Health Care Purposes
Does consent to the release of records to a third party have to be in writing?
Authorization does not necessarily have to be in writing, though it is good practice to obtain written consent for the release of records whenever possible. Members cannot insist on the patient’s written authorization prior to releasing records to a third party. If a patient is unwilling to sign a consent form, the member should clearly document the disclosure request in the patient’s chart and, where appropriate, ask the patient to initial the entry.
Do my communications with PLP about a patient form part of that patient’s chart?
Even the fact that you have contacted PLP is confidential and should not be recorded in a patient’s chart. Any communications with PLP about the patient should be kept separately in a clearly marked dental-legal file. In complying with a patient’s request for a copy of his or her chart or to disclose his or her records to a third party, care should be taken not to include information from the dental-legal file.
Can I ever deny a patient access to his or her dental record?
There are very few instances in which a patient can legally be denied access to his or her own health records, none that would likely apply to dental records.
Can I deny access to records if the patient has an outstanding account?
Withholding records because the patient has an outstanding balance is not permitted.
Am I required to transcribe the record?
If the patient requests it, a dentist should transcribe his or her handwritten chart entries.
May I charge a fee for providing or transcribing a record?
Dentists may bill for reasonable, out-of-pocket expenses incurred in providing a copy of a patient’s records, e.g. duplication and courier costs. However, they may not charge for staff time for compiling the record. And because dentists are obliged to maintain legible, understandable records, it is inappropriate to charge patients for transcribing handwritten chart entries.
Read more: RCDSO Dental Recordkeeping Guidelines
For more information, refer to the Practice Advisory Service FAQ on the release and transfer of records.