Records Management CUSTODIANSHIP AND OWNERSHIP OF PATIENT ...

CUSTODIANSHIP & OWNERSHIP OF PATIENT, RESIDENT AND
CLIENT INFORMATION
RM-CR(I)-010
PAGE 1/3

CUSTODIANSHIP AND Records Management
OWNERSHIP OF PATIENT,
RM-CR(I)-010
RESIDENT AND CLIENT
INFORMATION

Issuing Authority Carmel Turpin, Vice President
(sign & date) Signed by Carmel Turpin
Dated June 25, 2012
Office of Administrative Health Information Services and Informatics
Responsibility
Author Jim Brown, Director of Health Information
Services and Informatics
Level One (I)
Original Approval Date March 27, 2009
Effective Date Upon signature
Scheduled Review Date March 2011; June 2014
Actual Review Date
Revision Date(s) June 25, 2012

Policy

The patient, resident and client health record is the property of Eastern Health. The
information contained within the record is the property of the Patient, Resident and
Client.

The health record includes, but is not limited to, electronic, paper and film formats, in
multiple locations where Patient, Resident and Client health records may be held.

It is the responsibility of Eastern Health as custodian to maintain and protect both
the health record and the privacy of that information.

Scope

All employees and agents who use or have access to Patient, Resident and Client
health records.

CUSTODIANSHIP & OWNERSHIP OF PATIENT, RESIDENT AND
CLIENT INFORMATION
RM-CR(I)-010
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Purpose

To delineate ownership and custodian roles for the Patient, Resident and Client
health record.

Supporting Documents (References, Industry Best Practice, Legislation, etc)

 Personal Health Information Act
 Regional Health Authorities legislation, Section 6, sub-paragraph 1
 Access to Information and Protection of Privacy (ATIPP) Legislation

Key Words

 Custodian
 Media
 Personal Health Information
 Health Record

Definitions & Acronyms “Agent", in relation to a custodian, means a person
that, with the authorization of the custodian, acts for or
Agent on behalf of the custodian in respect of personal
health information for the purposes of the custodian,
Personal Health Information and not the agent's purposes, whether or not the
agent has the authority to bind the custodian, is paid
by the custodian or is being remunerated by the
custodian.

Identifying information in oral or recorded form about
an individual that relates to

a. the physical or mental health of the individual,
including information respecting the individual’s
health care status and history and the health
history of the individual’s family;

b. the provision of health care to the individual,
including information respecting the person
providing the health care;

c. the donation by an individual of a body part or
bodily substance, including information derived
from the testing or examination of a body part
or bodily substance;

Custodian CUSTODIANSHIP & OWNERSHIP OF PATIENT, RESIDENT AND
Media CLIENT INFORMATION
RM-CR(I)-010
Health Record PAGE 3/3

d. registration information;
e. payments or eligibility for a health care

program or service in respect of the individual,
including eligibility for coverage under an
insurance or payment arrangement with
respect to health care;
f. an individual’s entitlement to benefits under or
participation in a health care program or
service;
g. information about the individual that is
collected in the course of, and is incidental to,
the provision of a health care program or
service or payment for a health care program
or service;
h. a drug as defined in the Pharmacy Act, a
health care aid, device, product, equipment or
other item provided to an individual under a
prescription or other authorization issued by a
health care professional; or
i. the identity of a person’s representative or
guardian.

Custodian means a person or organization who has
custody or control of personal health information as a
result of or in connection with the performance of the
powers or duties of the work described

In communication, media (singular: medium) are the
storage and transmission tools used to store and
deliver information or data. The term is often referred
to as synonymous with mass media or news media,
but may refer to a single medium used to
communicate any data for any purpose. Media refers
to the physical property in which the information in
stored, such as, but not limited to, the paper, folder,
disk, hard drive, computer, etc.

A record of personal health information in any form,
and includes personal health information that is
written, photographed, recorded or stored in any
manner.