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Are you up to standard? Designating a successor custodian

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March Messenger 2024, Registration, Standards of Practice | Posted March 14, 2024
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If the last four years have taught us anything, it’s that there is nothing certain but the uncertain. This important lesson applies to many aspects of our lives, including the responsibility of regulated members to manage patient health information through their designation as custodians under the Health Information Act (HIA) and Health Information Regulation.

You are considered the custodian of any patient records you create or contribute to unless you are clearly identified as an affiliate. Under the HIA, an affiliate is an individual who is employed by a custodian or performs a service for a custodian as an appointee, volunteer or student, or under a contract agency relationship. As a common example, most healthcare providers (including physicians) employed by or performing services for Alberta Health Services (AHS) are considered affiliates of AHS, which acts as custodian of the health information entered into AHS systems.

When acting as a custodian, a regulated member must have policies and procedures in place in order to remain compliant with CPSA’s Patient Record Retention standard of practice. These must include an information sharing or information manager agreement (if applicable), establishment of processes to manage patient health information responsibly and clarification of the roles of all involved parties.

The careful management of patient health information is an important responsibility that must be maintained, no matter what circumstances are encountered. That is why all custodians are required to designate a successor custodian and must attest to having a successor in place on CPSA’s renewal information form during annual renewal each year. This requirement supports the retention and accessibility of patient records, regardless of unforeseen circumstances that may prevent a custodian from fulfilling their duties.

Successor custodians

Under the Patient Record Retention standard of practice, all custodians are required to designate an appropriate successor custodian. When determining who to designate, it is important to remember that not everyone is eligible for this role.

A successor custodian:

  • Must be eligible to be a custodian under the Health Information Regulation (per section 2(2));
  • Must be located near enough to the original custodian’s practice (in cases where they are not already working within the practice) to ensure patients continue to have reasonable access to their records, and;
  • Can be an eligible entity (as designated in section 2(1) of the Health Information Regulation).

Taking the step to identify a successor custodian is just one of the many ways that our regulated members support continuity of high-quality care and access to health information for their patients. More than just supporting patients, it shows consideration for your colleagues by minimizing the strain of assuming custodial responsibility and strengthening the efficiency of the profession as a whole.

Learn more about complying to this requirement by visiting the following links:

Questions? Contact Chantelle Dick, Standards of Practice Advisor, at

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