About the standard
The Patient Record Retention standard was last updated in 2016 and is being reviewed to ensure relevancy to current medical practices. A proposed title change to Patient Record Management better reflects the content covered within the standard. Guidance added regarding access, locum responsibilities and preventing abandoned records clarifies responsibilities of custodians and strengthens continuity of care. In accordance with the Health Information Act, EMR system requirements have been added to modernize and support current practices. Additional details regarding record storage, security and access requirements help support patients and transparency.
What’s changed?
- Proposed title change to Patient Record Management better reflects content detailed within the standard.
- Responsibilities of custodians clarified through addition of information regarding record access, locum responsibilities and abandoned record prevention.
- Requirements for EMR system added to align with the Health Information Act and ensure standards better acknowledge and reflect current practices.
- Additional guidance provided regarding storage, security and access requirements to support transparency of regulated member and patient rights.
- Retention timelines clarified for records specific to minors, deceased patients and any records involved in litigation or complaints.
View the draft standard
For your convenience, the draft standard has clean and marked copies available.
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Changes to CPSA’s Standards of Practice impact your day-to-day practice. Your feedback is important to us, as it helps us develop clear, reasonable expectations and helpful, applicable resources. We appreciate the time you take and the input you provide.
CPSA regulated members, partner organizations, other healthcare professionals and Albertans are invited to provide feedback from Jan. 6 to Feb. 5. Feedback may be provided via survey, email or the comment form on each page.
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Other feedback on this standard
Alberta's HIA became law in 2001. That was the year I finished med school, followed by 5 years of rural residency and locums, working in the charts of literally dozens of different "custodians". At that time, most private-practice doctors’ notes were hand-written (often on note paper provided free by drug companies, with ads in the margins!), some were dictated and typed out (and stuck onto said note paper), and a few were in a computer/EMR. Hospitals all had “medical records” departments storing floor-to-ceiling paper charts, and stacks of charts (usually not to the ceiling!) waiting for docs to finish dictating/signing things. Healthcare providers expected to get information from the patient/family, if it wasn’t in the chart they were holding, as there was virtually no access to information elsewhere (Netcare being a brand-new exception).
Entering 2026, that's essentially reversed - now nearly all notes live in one of a handful of EMRs (though not yet inter-accessible), and docs tend to look to the "digital patient" more than the real patient, at least for historical information. In Alberta, it's borderline malpractice to NOT access Netcare and/or Connect Care, when docs are caring for unfamiliar patients.
My point is that the paradigm of health information management in 2001 (and of this Standard of Practice, last updated in 2016) simply doesn't match up well with how health information works now. Tweaking the Standard (with the best intentions) won’t address some urgent questions for our profession:
- Patients share things about themselves with their healthcare providers because they trust us (more than almost anyone else!) and, very importantly, without any thought about the HIA or the CPSA Standards (which truthfully only apply when things hit the fan). How far can this trust be stretched without breaking, as patients’ health information becomes further removed from the control of the trusted provider with whom it was shared, to cloud-based tech companies (fairly low on the trusted list), and access is possible to anyone with a password? What happens to our profession when patients stop trusting that they can share these things with us? Or how will the CPSA advise us, when patients start asking us to NOT record information in their chart?
- Given the benefits of access to “complete” health information about a patient (while recognizing that “complete” does not necessarily mean either “accurate” or “meaningful”), where do we strike a balance when it comes to each of our privacy? Making it personal, do you want all your own personal health information accessible on Netcare/Connect Care without privacy limitations?
- When the nitty-gritty of health information storage/security rests solely with a handful of EMR vendors, what responsibility (apart from “not sharing your password”) is fair to put on the shoulders of individual “custodians” anymore? Does it make sense for docs to be responsible as “custodians” of electronic charts when they have no power over their storage/security (apart from a contract, written unilaterally by their vendor, which similarly applies only when things hit the fan)?
My suggestion is that the CPSA “not let a good crisis go to waste” here. Beyond tweaking this Standard on “Patient Record Management” from a 4-pager to a 9-pager, it would be great if the CPSA could start actively tackling some of these questions. Alberta is currently in a rather unique position regarding health information (both positive and negative), with a government happy to rewrite laws but that doesn’t know what it’s doing in this area. If the CPSA can provide some vision and/or roadmap for a better paradigm around health information, and those responsible (including CPSA) can make the needed structural changes, both the profession and patients will greatly benefit. Or we could kick the can further down the road, waiting until things hit the fan… 🙂
The use of templates on EMR seem to lead to very concise and in many cases inadequate information about patient encounters, and should be limited . Financial compensation for time spent on recording information is therefore essential . After one day of doing clinical work , I would spend 3 to 4 hours through the use of dragon speak , to capture everything