A patient record is the complete account of a patient’s care, comprising personal health information collected or generated by the pharmacy in any form or medium. The patient record includes the patient profile; patient and provider identifying information; data collected; assessment; notes documenting critical thinking and judgment, recommendations, interventions and discussions between members, other health care providers and patients; and prescriptions, records and reports that pertain to the patient’s care. All records and documents generated by members, and through the operation of the pharmacy, must be kept according to the standards of practice, code of ethics, and as required by legislation and regulation.
As a health information custodian, a pharmacy’s record keeping obligations are outlined in multiple acts and regulations. This guideline pertains specifically to the requirements established in the Personal Health Information Protection Act, 2004 (PHIPA), which governs personal health information in the custody and control of health information custodians and their agents. According to the Act, an agent means a person that acts for or on behalf of a health information custodian in respect of the collection, use, disclosure, retention, or disposal of personal health information. Health information custodians are responsible for the actions of their agents, and should therefore ensure that their agents comply with all of the obligations imposed on the custodian. In the case of a pharmacy, this obligation is shared with the designated manager as outlined in the Drug and Pharmacies Regulation Act, 1990.