Medical (Patient) Records

View more detailed information about medical/patient records here.

What is CPSM’s role with medical (patient) records?

Part of CPSM’s role is to ensure doctors in Manitoba follow the rules, act ethically, and maintain good records of the care they provide.

For more information, visit:

About CPSM

Protecting the Public

What is a patient record (medical record)?

A patient record is your health story at a clinic or hospital. It can include:

Notes from your doctor
Test results
Medicine lists
Dates of visits

All this information is referred to as personal health information (PHI). Learn more about your PHI rights.

Your patient record:

Should be kept safe.
Should only be seen by the right people.
Should be complete and clear.

You have rights to ask questions and get answers.

Who do I contact about my patient records?

Your question or concern	Contact
You are looking for your patient records or have a concern.	Start with your doctor or clinic. Many issues are simple mix ups and can be resolved directly with your doctor. If you are unsuccessful in resolving the issue or getting a response, contact CPSM.
Questions about how your doctor keeps or organizes your record	CPSM
Concerns about privacy under the PHIA law (how info is collected, used, shared, protected, or corrected)	Manitoba Ombudsman
You’re not sure where to begin	If you’re unsure, contact CPSM for assistance.

When to contact CPSM:

CPSM focuses on doctors’ professional duties and record-keeping.

Ø If you have questions or concerns about how your doctor or medical clinic:

· Collects your information

· Uses your information

· Stores/maintains your record

· Shares (discloses) your information

Ø If you are having trouble accessing a copy of your patient record.

How to contact CPSM:

Phone: (204) 774-4344
Toll Free: (877) 774-4344
Email: cpsm@cpsm.mb.ca

When to contact the Manitoba Ombudsman’s office:

The Ombudsman checks whether clinics and doctors are in alignment with The Personal Health Information Act (PHIA).

The Manitoba Ombudsman’s office – which is separate from CPSM - makes sure health care providers follow PHIA. Click here to learn more about the Manitoba Ombudsman.

Ø The Ombudsman's office looks at concerns about how your information is:

· Collected

· Used

· Shared (disclosure)

· Secured/protected

· Corrected

· Accessed

How to contact:

Phone: 1-800-665-0531

Email: ombudsman@ombudsman.mb.ca

Applicable Standards of Practice:

Ø Standard of Practice for Documentation in Patient Records

This Standard of Practice sets out requirements for all registrants to ensure accurate, complete, and timely documentation in patient records, supporting:

continuity and quality of care,
patient safety, and
legal and regulatory compliance under the Regulated Health Professions Act and the Personal Health Information Act.

Ø Standard of Practice - Maintenance of Patient Records in All Settings

This Standard of Practice sets out requirements for registrants maintaining patient records in Manitoba across all practice settings (paper or electronic, in-person or virtual care). The Standard focuses on protecting the privacy and security of personal health information. It also clarifies custody, control, and transfer responsibilities to prevent abandoned or inaccessible records.