Clinical Notes and Records
In any lawsuit in Ontario, be it criminal, civil, family or personal injury/insurance, the Rules of Court mandate that parties exchange relevant documentation that they have, or information pertaining to documentation or other relevant information that they know to exist, be it in their possession or not.
Most often, the request for documentary information originates with a third party.
The purpose of timely exchange of information is to facilitate a resolution of the dispute between the parties.
The Rules of Court are designed to facilitate settlement and avoid court.
As in most Court mandated processes, the Court is the ultimate arbiter of what is relevant, and what is fair compensation for the burden of being forced to provide information in proceedings to which you are not a party.
Physicians must be compensated for the provision of notes and records in a fair way.
From a legal perspective, the principal rules for reimbursement for providing notes and records are:
- Fees are for photocopying and staff time only
- Fees for review of records will only be paid if the review of records was specifically requested
- If records are illegible, a fee will be provided for the “transcription” of the records but that fee should be negotiated in advance
When you are asked to provide a copy of your patient’s notes and records, it is important that you provide all of your notes and records. However, as often as not, your patient’s lawyer will put a time limit as to how far back in time the records should go (eg. 3 – 5 years preceding the incident in question up to the date of request).
As with most things, good and accurate communication avoids misunderstanding. If you are not clear as to what exactly is being requested of you, you can always ask for clarification. At out law firm, we are pleased to respond to individual physician’s requests for explanations.
Keep in mind that in the end, if the third party refuses to pay for the service, or if the Court will not enforce the request of the physician for payment from the third party, the patient will be responsible for the fee. If the fee is exorbitant or not commensurate with the request, the patient may complain.
At out firm, if the request for notes and records emanates from our office, we pay upon receipt of the records, or in advance if requested. If the request is made by an opposing party, we will pay for the records as soon as that party makes payment.