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Procedures and Guidelines

Resident Records and Access to Information

Categories: Access Resident Records PGME

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Purpose

This policy is to establish the process of accessing resident files and to outline the content, security, retention, and release of confidential information within PGME and Program resident files.

Throughout a resident’s training there may be instances where access to a resident’s file is required by parties within or outside the University. Such instances may include (not limited to): transfers, program accreditation, appeals or verification of training.  All resident files are considered confidential.  Not all parts of a resident’s file are “releasable” to the resident or to others, due to legal and contractual constraints that prevent such release. Information considered non-releasable would only be released where there is a legal obligation to act or cooperate in an extra-University judicial process.

This policy is being written in accordance with the CanRAC accreditation requirements.

Definitions

Postgraduate Medical Education (PGME) Office refers to the Associate Dean, PGME and the administrative personnel who are responsible for coordination and administration related to the oversight of the residency training programs.

Program is the Royal College of Physicians and Surgeons of Canada (RCPSC) or the College of Family Physicians Canada (CFPC) accredited residency training program at the College of Medicine.

Resident refers to postgraduate medical trainee enrolled in the RCPSC or the CFPC program.

Resident File refers to the PGME (administrative) and/or Program (academic) record of the postgraduate resident enrolled in the RCPSC or the CFPC program.

Scope of this Policy

This policy applies to all residents either currently enrolled or previously enrolled in a residency training program at the College of Medicine, University of Saskatchewan.

This policy has been adapted with permission from Dalhousie University Records Access to Postgraduate Trainee Files Guidelines.

Policy

  1. Resident Access to Resident’s Own Files:
    1. Any Resident wishing to access his/her Resident File maintained by the residency training program or by the Postgraduate Medical Education Office must schedule an appointment 24 hours in advance with either the office of the Program Director or the Postgraduate Medical Education Office.
    2. Throughout the time that a Resident has access to his/her Resident File, the Resident shall be supervised to prevent removal or alteration of any of the contents of the file.
    3. Prior to permitting a Resident to review a Resident File, the Program Director or staff in the Postgraduate Medical Education Office shall remove from that file the following confidential information: letters of reference pertaining to the Resident; other evaluative or opinion material compiled solely for the purpose of determining the Resident’s suitability or qualifications for admission, employment or promotion, where the information was provided in confidence; material pertaining to any complaint, appeal, or other action concluded or currently underway, whether academic or non-academic; material subject to solicitor-client privilege, or material prepared by legal counsel for or on behalf of the University; other documents protected under the Local Authority Freedom of Information and Protection of Privacy Act, or similar legislation.
    4. The Resident may be provided, upon request, with an inventory of the confidential documents in their Resident File. The inventory shall not identify the author, or the substance of any confidential material, but shall list confidential documents only by date, general subject, purpose for which solicited, and the person by whom it was solicited or whether it was solicited.
    5. The Program Director’s office or the Postgraduate Medical Education Office may provide a Resident with copies of the contents of that Resident’s File (except for those items listed above).
    6. Access to information can also be requested from the University of Saskatchewan, Access and Privacy Officer by making a formal request/application. If a Resident is not satisfied with the disclosure under this policy, they have the right to contact the Access and Privacy Officer and/or make a formal access to information request which will be processed by the Access and Privacy Officer.
  1. Other Access to Resident Files:
    1. The PGME Associate Dean and PGME staff will have access to information within administrative Resident Files as required to ensure proper management of a Resident’s training. PGME staff are bound by the confidentiality agreements in place upon commencement of employment by the University of Saskatchewan.
    2. Those with a role in the Resident’s education such as Program Directors, Assistant Program Directors, Site Directors, Program Administrators, Residency Program Committee/Competence Committee and Academic Advisors may have access to information within a Resident’s academic file as required to ensure the proper management of the Resident’s training. Program faculty and staff are bound by the confidentiality agreements put in place upon commencement of employment by the University of Saskatchewan or Saskatchewan Health Authority.
    3. Accreditation survey teams approved by the University of Saskatchewan shall be granted access to Resident Files for the purpose of conducting an audit or review in connection with authorized institutional or program accreditation processes.
    4. Other third parties as determined by the PGME Associate Dean to have a legitimate interest and as permitted or required by law.
    5. Access to information can also be requested from the University of Saskatchewan, Access, and Privacy Officer by making a formal request/application. Anyone not satisfied with the disclosure under this policy, has the right to contact the Access and Privacy Officer and/or make a formal access to information request which will be processed by the Access and Privacy Officer.

 

 

  1. Content, Security, Retention and Release of Resident Files:

Content of Resident Files:

  1. Information found within PGME, and program level Resident Files is shown in Appendix A.

 

Security of Resident Files:

  1. A permanent, confidential PGME administrative file (managed by PGME) and program academic file (managed by the program) will be created and maintained for each Resident upon admission to a residency training program the University of Saskatchewan. These files may be electronic, or paper based.
  2. All electronic Resident Files held by the PGME office, or the program will be stored securely in accordance with University of Saskatchewan or Saskatchewan Health Authority IT security guidelines. As of 2020, PGME Resident Files are electronic.
  3. All PGME paper based Resident Files created prior to 2020 will be recorded and stored in a designated secure location. The PGME office may submit and retrieve Resident Files from the secure location as required and in accordance with this policy
  4. Program paper based academic files must be kept in a locked, secure cabinet in a designated secure location within the Resident’s program office.

 

Retention of Files:

  1. PGME and program paper files created prior to 2020 will be kept for 60 years or 2080, whichever comes first. For example, a file created in 1972 would be destroyed in 2032, files created in 1995 would be retained until 2055 etc. 
  2. Paper files may be converted to electronic files then stored at the discretion of PGME and/or the program.
  3. PGME and program electronic files will be destroyed after 60 years.

 

Release of Resident File Information:

  1. Types of confidential information that may be released is shown in Appendix A.
  2. Previous UofS Residents can request a postgraduate verification of training by contacting the PGME office. See PGME verification of residency training.

 

Release of Resident File Information for Educational Purposes:

  1. Upon registration as a Resident at the University of Saskatchewan, Resident information may be disclosed without the Resident’s express consent to affiliated agencies of the University of Saskatchewan. Affiliated agencies are listed in Appendix A.

 

    1. Data Management:

The Postgraduate Medical Education Office adheres and is subject to the University of Saskatchewan Data Management Policy. The policy provides a framework to safeguard and protect the university’s data while providing flexibility to support the broad range of academic, research and administrative activities at the College of Medicine. The policy covers all university data regardless of where it is stored (on campus or off campus), where it is being accessed from (on campus or off campus), and whether the data is in raw form, derived, summarized, or aggregated.

Data Steward:

Data Stewards are senior university officials (typically at the level of directors, deans, and Principal Investigators or their delegate(s)) in university units who are responsible for promoting appropriate use of data through planning, policy, and protocols at the university. Under the U of S Data Governance Framework,

Data stewards have stewardship responsibilities for particular elements and/or aspects of institutional data. As individuals, data stewards have specific responsibilities and authority for the management, access, use, definition, and quality of data that pertains to their functional areas and/or is deemed to be under their purview.

The data steward is responsible for approving and ensuring compliance regarding the release of, responsible use of, and access to data for which they are responsible.  Some of these responsibilities include:

  • Providing governance oversight for data within their area of responsibility, including:
    • Defining the scope of data domains and approving changes.
    • Reviewing and approving data definitions, compliance, and access classifications (public, internal, limited, and restricted).
    • Reviewing quality metrics and assessment of progress toward improvements in data integrity.
    • Prioritizing data issues for resolution.
  • Approving the use of institutional data for which they are responsible, for the purposes of research.

The data steward for PGME resident data is the PGME Associate Dean.

For research purposes, ethics or other approvals does not guarantee that access to data will be approved by the College of Medicine/PGME. 

The Data Management policy defines university data and institutional data:

  • University data – Data that is created, collected, and stored (either electronically or in hard copy) by units and members of the university community, in support of academic, research, and administrative activities.
  • Institutional data – Data that is created, collected, and stored by all units and members of the university community, in support of academic and administrative activities. Administrative data about teaching, learning, research, and scholarly activity, such as grades, attendance, research grants held and publications generated, is considered institutional data.

Non-Compliance

Instances or concerns of non-compliance with this policy should be brought to the attention of the Associate Dean, PGME.

References

Contact

Coordinator for Academic and Non-academic Processes, PGME Office
Phone: 306-966-6145

Appendix A

Content of Resident Files:

TYPES OF CONFIDENTIAL INFORMATION: RELEASABLE VERSUS NON-RELEASABLE Legend:

Y:            Confidential information that may be released upon request by the party (information to which the party would generally have provided or require as part of normal business).

N:           Confidential and generally “non-releasable”. Will not be released or viewed without a legal obligation to release. Generally confidential but may possibly be released through successful FOIP request.

R:              Confidential and releasable only on request and with permission from the Resident.

 

Confidential Information held at PGME Office

Type of information to be released

Destination of Released Documents

Trainee

RPC (including admin supports), Competence Committee, Program Accreditors

Colleges, Hospitals and Other Educational Institutions

UofS Affiliated Agencies

All Other 3rd Parties

Application records (CARMS, or other processes) EXCEPT letters of reference and official transcripts

Y

Y

N

N

N

Reference letters received, official transcripts from other institutions

N

N

N

N

N

Personal Information Profile collected during annual PGME registration

Y

Y

R

Y

N

PG Deans recommendation letters

Y

Y

R

N

N

Letters received or written at the request of the post graduate trainee regarding health or personal issues that affect academic progress or performance

N

Y

N

N

N

Physician letters regarding health-
related matters

N

N

N

N

N

Outcome letters from appeals

Y

Y

R

N

N

Supporting documents from appeals

N

N

N

N

N

Notes to file based on Trainee meetings

Y

Y

N

N

N

Documents related to Trainee requests, including but not limited to: transfers, grievances, verification of training and accommodation.

Y

Y

N

N

R

Letters regarding legal matters not pertaining to the current training position, such as request for verification of training

N

N

N

N

N

Confidential Information related to Assessments and Progress

Types of Documents

Destination of Released document

Trainee

RPC
(including
admin
supports),
Competence
Committee,
Program
Accreditors

Colleges, Hospitals, and other educational institutions

UofS Affiliated Agencies

All

Other
3rd

Parties

Information on academic progress (e.g., Assessments, exam results, EPAs, etc.)

Y

Y

R

N

N

Transcripts of academic performance

Y

Y

R

N

N

Registration information

Y

Y

R

R

N

Scholarship applications

Y

Y

R

N

N

Other unsolicited general Trainee performance letters (e.g., letters of thanks from patients/families, notification of awards)

Y

Y

R

R

N

Enhanced Learning Plans, Remediation & Probation documents

Y

Y

R

N

N

Documents related to certification

Y

Y

R

R

N

 

Confidential Documents held by Residency Training Programs

Program director notes to file, including but not limited to: notes on training progress, counselling, incidents or issues that impact training

Y

Y

R

N

N

Trainee requests, including but not limited to: leave request for illness, vacations, conferences, parental leave, requests for waiver of training, accommodation

Y

Y

R

Y

N

Summary of 360 evaluations

Y

Y

R

N

N

Informal Enhanced Learning Plans (IELPs)

Y

Y

N

N

N

Documents leading to certification i.e. CCTs (RC), STACERS, FITERs, e-FITERS, Confirmation of Training (CFPC) AFCs

Y

Y

R

N

N

 

Release of Resident File Information for Educational Purposes:

Agencies include (not limited to):

Information provided:

UofS I.T. Department
(NSID creation)

Resident Name, Date of Birth, Gender, Address, Phone Number, Email Address

CPSS, SHA, SMA Office

Resident Name, Program, Site, PGY, Email, Start Date

RDoS Office

Resident Name, Program, Site, PGY, Email, Start Date, Promotions, Completions, Transfers, Resignations, Leaves

UofS Admissions &
Connection Point

Copies of completed Resident Registration/Personal Data forms