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Record-keeping essentials
What a clinical record holds, how to write and amend it, appointment and financial records, how long to keep them, how to keep them safe, and a client's rights of access and correction.
Study aid, not legal advice.Last verified against the official sources linked below on .
What the clinical record holds (Standard 5.1)
- Client profile: name, address, phone, date of birth, any legally authorized representative, who referred and why.
- Assessment: methods, results, conclusions, problem formulation.
- Plan for therapy, with each consent given.
- Progress notes: the client's statements, your observations, impressions and plans.
- Consultations and referrals, each with its date and details.
- Reports sent or received; a copy of each mandatory report, or a written summary of a verbal one.
- Incident reports for any major, unexpected negative outcome, with action and follow-up.
- Closing: reasons, a summary of outcomes, referrals or follow-up.
- Not part of it: rough notes (complete the record, then destroy them the same day) and notes on your own process that do not identify the client.
How to write it (5.1)
- Accurate, complete, legible, in plain language, updated in a timely way (5.1.1).
- Key information in English or French; progress notes may be in the language of therapy.
- Each entry shows the client's name or unique identifier, the date, and who wrote it.
- Amend openly: what changed, when, by whom and why, the original still legible.
- Misconduct: failing to keep records to the profession's standards, signing a false or misleading document, or falsifying a record (O. Reg. 317/12, s. 1, paras. 25 to 27).
Appointment and financial records (5.4, 5.5)
- Appointments: an appointment and attendance record for each client, with the date, time and length of each encounter and any cancelled or missed appointment (5.4.1); central or in each file.
- Financial record for every client charged a fee (5.5.1): who provided the service and their title; the client's full name, address and any unique identifier.
- The service, its cost, and the date and method of payment; fees for services by supervised personnel.
- Reductions or waivers and why; a third-party payer's full name and address; any balance owing; any collection agency retained.
- Separate from the clinical record if you wish, but secure and easy to retrieve (5.5 commentary).
How long to keep them
- Example: last seen at age 7, kept until the 28th birthday.
| Record | Keep at least |
|---|---|
| Clinical (5.1), when you are the custodian | 10 years from the last interaction or from the client's 18th birthday, whichever is later |
| Appointments (5.4) | The same |
| Financial (5.5) | The same |
Keeping them safe (5.6)
- Reasonable steps against theft, loss, and unauthorized use, disclosure, modification or disposal (5.6.1).
- Policies: write them if you are the custodian (you, in solo practice); otherwise follow your group practice's or employer's.
- Physical: locked spaces, screens out of view, micro-cut shredding.
- Electronic: firewalls, encryption, passwords, tested backups, an audit trail of entries, views and exports, a fallback if the system fails.
- Administrative: need-to-know access, confidentiality agreements, privacy training, a disposal log.
- In transit: tracked mail or courier, or encrypted transmission.
- Your system must retrieve, transfer, amend (keeping the original) and securely destroy records, organized so they are easy to find.
Access and correction (PHIPA ss. 52 to 55)
- A right of access, except where it could, for example, risk serious harm to treatment or recovery, or serious bodily harm (s. 52 (1) (e)); give what can be severed (s. 52 (2)).
- In writing, with enough detail to find the record (s. 53).
- Answer within 30 days at most; one extension of up to 30 days, with written notice (s. 54 (2) to (4)). No answer is a deemed refusal (s. 54 (7)).
- A fee no higher than reasonable cost recovery, which you may waive (s. 54 (10) to (12)).
- Correction: correct what the client shows is inaccurate or incomplete, within the same 30 days (s. 55); a good faith professional opinion need not change. A refused client may attach a statement of disagreement.
Write it plainly, amend it openly, keep it ten years after the later date, and let clients see it.