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College Mandate:  Correcting Errors in a Medical Chart

Onus on Patient to Recognize Errors & Write Amendments,
But College Position Breaches Federal PIPEDA Legislation

Health and Business Records: Privacy and Right of Amendment

·  Provincial HIPA Not Always Compliant with Federal PIPEDA

Compliant Provinces
Currently, only six Canadian provinces have enacted HIPA privacy laws that are deemed substantially similar to the Federal PIPEDA legislation:
British Columbia Ontario New Brunswick
Alberta Quebec Newfoundland & Labrador
Non-Compliant Provinces
The remaining provinces and territories also have their own HIPA laws, but these are not substantially similar to the Federal PIPEDA.  In these regions, an application under PIPEDA may succeed:
Saskatchewan Nova Scotia Nunavut GNWT
Manitoba Prince Edward Island Yukon Territory
Source: Privacy Legislation in Canada Fact Sheet

Letter:  College of Physicians and Surgeons of Saskatchewan

Onus for Chart Integrity Placed Squarely on Patient



Direct all correspondence
to the Registrar

College of
Physicians and Surgeons
of Saskatchewan


Business: (306) 244-7355
(306) 244-0090 (General)
(306) 244-2600 (Dr. Kendel)

OUR FILE: #12/02

Ms. Georgena Sil
P.O. Box 1491

Dear Ms. Sil:

As Medical Manager of the Complaints Investigation and Resolution Process of the College of Physicians and Surgeons, I have reviewed the information you referred to the Registrar in your letter dated June 8, 2001.

I would advise that the College of Physicians and Surgeons does not keep information such as this on file unless it is part of an ongoing investigation of one of the College's committees. I would suggest that you have done the appropriate thing by taking your concerns directly to Dr. Wine in your two letters with respect to information that you felt was inaccurate in your record. As physicians cannot change the records, can only make addendums to them, your letters may be added to your file in Dr. Wine's office to indicate that you disagree with the information contained in that file.

The information you sent to us is being returned with this letter. You may wish to retain it on file yourself. If at a later date you wish to place a specific complaint against the care provided to you, I would be pleased to receive the information at that time.


Karen Shaw, M.D.
Medical Manager
Complaints Investigation and Resolution Process


Competent caring Physicians providing quality health care.

Nammo v. TransUnion of Canada Inc (2010) FC 1284

PIPEDA:  Practical Interpretation by the Courts

PIPEDA does not require that health data be completely accurate, complete, and up-to-date; rather, it requires that health data be as accurate, complete, and up-to-date as is necessary for the purposes for which it will be used. Thus, it is the use that the information is put to that dictates the degree of accuracy, completeness, and currency the information must have.

An organization cannot escape responsibility for complying with the Accuracy Principle under PIPEDA merely because the organization has chosen a system that is commercially sensible. There is no defence of practical necessity set out in PIPEDA.

Canadians need a means to challenge industry standards. A breach of PIPEDA does not depend on whether an organization's practices fall below industry standard. The practices of an entire industry may run counter to the Principles laid out in PIPEDA Schedule I.

An organization's duty to assess the accuracy, completeness and currency of health information is an ongoing obligation. It is not triggered only when the organization is notified by individuals that their personal data is no longer accurate, complete or current.

The responsibility for monitoring and maintaining accurate records cannot be shifted from organizations to individuals.

In circumstances where it is appropriate for an organization to notify third parties to whom it had previously disclosed inaccurate information, it must also provide the actual amended information in order to set the record straight.

PIPEDA: Personal Information Protection and Electronic Documents Act
Schedule I

Principle 6 – Accuracy

4.6  –  Accuracy: Personal information shall be as accurate, complete, and up-to-date as is necessary for the purposes for which it is to be used.

4.6.1  –  The extent to which personal information shall be accurate, complete, and up-to-date will depend upon the use of the information, taking into account the interests of the individual. Information shall be sufficiently accurate, complete, and up-to-date to minimize the possibility that inappropriate information may be used to make a decision about the individual.

4.6.2  –  An organization shall not routinely update personal information, unless such a process is necessary to fulfill the purposes for which the information was collected.

4.6.3  –  Personal information that is used on an ongoing basis, including information that is disclosed to third parties, should generally be accurate and up-to-date, unless limits to the requirement for accuracy are clearly set out.

Principle 9 – Individual Access

4.9.5  –  When an individual successfully demonstrates the inaccuracy or incompleteness of personal information, the organization shall amend the information as required. Depending upon the nature of the information challenged, amendment involves the correction, deletion, or addition of information. Where appropriate, the amended information shall be transmitted to third parties having access to the information in question.

4.9.6  –  When a challenge is not resolved to the satisfaction of the individual, the substance of the unresolved challenge shall be recorded by the organization. When appropriate, the existence of the unresolved challenge shall be transmitted to third parties having access to the information in question.

Georgena S. Sil
Saskatoon, Canada
Physicist & Technical Writer
Alumnus: University of British Columbia
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Created half to rise,
and half to fall;

Great lord of all things,
yet a prey to all;

Sole judge of truth, in
endless error hurled;

The glory, jest, and
riddle of the world!

Alexander Pope

Essay on Man (Epistle 2)


Blueprint of a Medical Chart

A medical chart has four main segments titled symptoms, signs, diagnostics, and treatment.

  • Symptoms are what the patient reports.
  • Signs are what the doctor observes when directly examining the patient.
  • Diagnostics include lab tests, scans that see inside the body, and biopsy results. These are considered the gold standard because they measure the organic and physiologic basis of a disease.
  • Treatment could be a series of stepped options increasing in potency or risk. The response to treatment either confirms or refutes the diagnosis.

Build Your Personal File

To build a personal copy of your chart, at a minimum ask for:

  • Diagnostic reports. The requisition is also useful, as it contains a slot for the clinical picture (where the doctor writes down the reasons for ordering the test).
  • Consultation reports from specialists, plus the Referral Letters written by the family doctor
  • The Clinical Chart (also called Progress Notes). These are hand-written notes made by the doctor at each patient visit.

Records from Reluctant MDs

The Canadian Supreme Court paved your way in McInerney v. MacDonald (1992) SCC, which ruled: Patients have the right to obtain a copy of their chart from a clinic or hospital. While the physical paper belongs to the doctor, the information belongs to the patient.

With that precedent, the College of Physicians and Surgeons of each province, who formerly frowned on informed patients, did an about-face and is now your best ally for obtaining records from a reluctant MD.

Where the College falls down is their minimal approach to correcting mistakes in the record. This applies to the 7 provinces and territories non-compliant with PIPEDA.

Copyright © 2008-2019 Georgena Sil. All Rights Reserved.