Canadian Medical Records (National Institute)

Each province sets out its own laws in regards to the keeping of medical records. For example, in Ontario, hospitals, medical records, notes, charts and other material relating to patient care are covered under provincial legislation. If the person is 18 years or older, the records are kept for 10 years. If the person is under 18, the records are kept 10 years after the person turns 18. Diagnostic images are kept for 5 years if the person is over 18, or if the person is under 18, for 5 years after their 18th birthday. After this, the records can be destroyed. Every province in Canada has a different hospital act, so what happens to medical records in Quebec could be totally different from what happens to medical records in British Columbia.

So, what becomes of medical records, and is it possible to view a relative’s medical records? I posed this question to people who work with medical records every day. First, I contacted Ani Orchanian, Chief Archivist/Information Specialist, at the University Health Network, Princess Margaret Hospital Toronto. Here’s what she had to say:


 * “If you are looking for medical records of an ancestor, where would be the best place to start? The medical records of an individual belong to that individual. So, for example, if you were looking for your birth record, that would be the mother’s record and not yours. Only the individual would have access to their own medical record. Even if the medical record of your ancestor was for some reason not destroyed when the retention time expired, you would not be given access due to privacy/confidentiality reasons. The best place to start? I don’t know. You could always try contacting the hospital where they died or were treated, but chances are they would not allow you access to the record if it still existed.”

I also contacted Jon Schmitz, Archivist and College Historian for the College of Physicians and Surgeons of Ontario. He says:


 * “I’m not sure this will answer your question, but the number of years a health record must be kept is a matter of Provincial legislation and regulation, i.e. you’d need to contact each Provincial College or Medical Board. Moreover, these regulations apply to hospitals and individual physicians, not to the records themselves. In other words, a hospital is required to keep records according to the Hospital Act. Similarly, a physician is required to keep records for the set time period; however, if the physician should die or resign, the College has no authority over estate or person who acquires them, and no authority over how they are kept or accessed. The exception to this in Ontario is health records from mental health institutions, which are in the Provincial government’s custody.”

Simply stated, obtaining medical records is a hit or miss proposition. I’ve been able to obtain the medical records of my great-uncle, who died in a veteran’s hospital in 1959. On the other hand, last year when I tried to get my own medical records, which are much newer than my great-uncle’s 43-year-old records, I found that they had already been destroyed. Still, it’s worth the effort to try to obtain any available medical records, as there is a great amount of information to be gained for these papers!

Because health care is a provincial matter and each province has its own legislation, it is always a good idea to check with each individual provincial archives to see what has happened to that province’s medical records. Here is what I was able to find out (in alphabetical order by those provinces that responded to my queries):

Manitoba

 * “Unfortunately, if a genealogist is looking for an ancestor’s medical records, they won’t have a lot of luck. The Provincial Archives does not keep medical records; they belong to the hospital. I am not sure how long the hospital keeps them before they are destroyed. The only thing that a person might find at the Archives are the Chief Medical Examiner’s reports.”

Northwest Territories
From Ian Moir, Senior Archivist:


 * “I believe that that there is legislation regarding the length of time certain types (categories) of medical records must be kept (This may be federal legislation—I am not sure...) however—I am not aware of any legislation that specifically directs the acquisition of medical records by an archives. Each archive and medical institution for that matter—may have differing opinions as to where long term preservation of records is best handled. Moreover—in any given jurisdiction—there may be different relationships between the medical institutions and the provincial archives. Finally— accessing medical records may be somewhat problematic in so far as Privacy Protection legislation may impede access to records.” 

Ontario
From Ryan Taylor’s book Routes to Roots, on the subject of the Archives of Ontario:


 * “Doctor’s records can be found there. These are often account books, with single pages indicating the amounts owed by one family. It is possible to use these records to follow the course of an illness, although the information given is slight. If you are lucky, a more detailed journal may be included. These records come from all over, and are in the Archives of Ontario by chance. There is a published guide, which is available in the Reading Room. If you do not find a local doctor there, check in archives which are closer to where your family lived.


 * [Carolyn] Heald [of the Archives of Ontario] told how the true story of the death of Susannah Doner in 1872 was revealed by her doctor’s journal. The story was that she had been jilted and died of a broken heart. The doctor’s records revealed she had an illegitimate child, which caused her to leave her parent’s house. She died of complications from the delivery, and the fate of the baby is not known.


 * Heald also mentioned that obstetrical details of the births of children, particularly difficult births, may be found in these records. These will be of great interest to anyone compiling a medical family tree. Quite substantial records can be found at the Archives for psychiatric hospitals and tuberculosis sanatoria, both of which are run by the provincial government.


 * Records for the Queen Street Hospital in Toronto go back to its beginnings in 1839. There are nineteenth century records for the institutions in London, Hamilton, Kingston and from Penetang from 1904.


 * These records largely consist of death and discharge records, admissions and case logs. As you might guess, it is possible for some of them to be lengthy and detailed.


 * These documents are governed by the Freedom of Information Act and the Mental Health Act. If you have a relative who spent time in one of these hospitals, you should begin by looking at these two acts to determine what records might be made available to you, and under what circumstances.


 * For those who died in the care of provincial hospitals, there may be estate files, which are listed alphabetically in the finding aid for the hospital records in the reading room at the Archives.”

Archives Ontario also provides Research Guide 224:Patient and Health Practioner Records which describes the records they hold of patient and practioners. These records include some from Brockville, Hamilton, London, Toronto, Kingston, Penetanguishene and Whitby among other places. This guide is available at the above link.

Prince Edward Island
From Marilyn Bell, the Provincial Archivist for PEI:


 * “Medical records are a grey area in terms of records management, at least in this province. Hospitals here are not considered to be part of government and do not come under the provincial records management program except for some personnel records. Hospitals may or may not have records management programs themselves which determine which records are kept and for how long. Access to those must be through the hospital administration.


 * And then, of course, there are the records kept by individual doctors which are generally considered to be their own personal records and they alone make decisions concerning how long they are kept, if they are left for the doctor who takes over the practice, if they are destroyed, or if they are offered to an Archive. I would expect that most Archives would be quite leary of taking on a doctor’s files because of the confidentiality factor.


 * In the PEI Public Archives and Records Office, we have a few doctors’ record books which have minimal information, generally being more of an account book rather than a case book, listing date, time, brief indication of the reason for the visit, and the fee. These tend to be from the 1920s and 1930s. I suspect that records prior to that date are practically non-existent although we do have some sketchy records from the Falconwood, Hillsborough, Riverside Hospital.


 * So much of health care was in the hands of rural community doctors until well into this century that the best avenue would probably be to determine where your ancestor lived, where and who the closest doctor would have been and then try to determine the status and location of such records. I would not hold out much hope for the continuing existence of such records or the quantity of information contained therein.”

Saskatchewan
From Chris Gebhard, Chief Archivist, Reference and Special Media, Saskatchewan Archives Board:


 * “The reason that medical records have been preserved (or not preserved) in such an uneven fashion is that until very recently, no legislation existed that dealt with this issue. Medical organizations and practitioners managed their own records and made their own decisions as to disposal and retention. We do not have a large volume of such records in our holdings, nor is there a central repository in our province. As is the policy with all personal information, access to health records in our holdings is restricted. If you are looking for health records of an ancestor, the most appropriate place to start would be the current Health District where the individual once resided. At present, there are 14 Health Districts in the province."

Yukon
From Lesley Buchan, Government Records Archivist:

''“Your questions regarding Yukon specifically can be answered as follows. In about the mid-1990s Yukon hospitals transferred from the federal government to a separate Yukon corporation called the Yukon Hospital Corporation. While under federal control, Yukon medical records would have been covered under federal legislation and records schedules. After the change to territorial control, the YHC is in charge of their own records and do not legally have to send them to the Yukon Archives. Theoretically they could start their own archives but I don’t know if they have. A contact number for them is 867-393-8700.''

''The Yukon Archives does have a few collections of medical records from private church hospitals before they came under federal control in 1963. If you would like specific information on what Yukon Archives holds with regards to genealogy and medical records I could send you the fonds level descriptions for those fonds. Also if you are interested in what total genealogical records we hold, we have a draft finding aid listing all our sources which I could send you.” ''

So, it appears that some Provincial Archives have medical records, and some do not. The road to finding medical records looks long, but not impossible. It is best to start at the medical records department of the hospital where your ancestor was treated, or with the doctor who treated your ancestor. If the records are not there, ask what happened to them. Were they microfilmed? Were they donated to an archival institution? Were they shredded? In Ontario, there must be written documentation of the destruction of the records, with a list of the names of the patients’ records that were destroyed. Of course, this is a modern regulation, so if the documents were shredded 90 years ago, there’s not really much you can do.

Why would anyone bother going to the trouble of trying to find medical records? To begin with, medical records contain a great deal of information pertaining to a person. The following lists only a few of the types of information you can find in medical records:


 * person’s name
 * age
 * birth date
 * address
 * next of kin
 * allergies
 * medical conditions

More and more people these days are attempting to put together a medical family tree, in order to find out what diseases are prevalent in their family. If breast cancer or heart disease run in the family, it’s always best to be aware of these conditions, so all precautions can be taken to catch these diseases before it is too late. Any medical record you are able to obtain gives you that much more information about the diseases that run in the family, and what you should be looking out for.

Books
Below is a list of books that give some help in finding medical records across Canada:


 * Canadian Nurses’ Association. Guide to the Historical Collections of the Canadian Nurses’ Association. (Ottawa, 1987).


 * Craig, Barbara L. A Guide to Historical Records in Hospitals in London, England and Ontario, Canada c. 1800-c. 1950. Part 1: An Overview of the Continuities and Changes in the Content and the Form of the Records. Canadian Bulletin of Medical History 8:2 (1991): 263-287.


 * Craig, Barbara L. A Guide to Historical Records in Hospitals in London, England and Ontario, Canada c. 1800-c. 1950. Part 2: A Consolidated List of Records. Canadian Bulletin of Medical History 9:1 (1992): 71-141.


 * Dunn, Margaret, comp. A Directory of Medical Archives in Ontario. (Toronto, 1983).


 * Flemming, T. and D. Kent. Sourcebook of Canadian Health Statistics. (Toronto, 1990).


 * Heckford, Ian J. and Susan Stanley. Griffin-Greenland Archives on the History of Canadian Psychiatry: A Guide to the Collection. (Toronto, 1987).


 * Lewis, Jim. A Guide to the Medical Archives of British Columbia. (Vancouver, 1988).


 * Liebenberg, Gillian. A guide to health care history materials in New Brunswick. (Fredericton, 1997).


 * MacMillan, Kathleen and Judith Young.A Guide to Historical Nursing Materials in Ontario. (Toronto, 1994).


 * Morin, Colette.Indices for a Directory of Medical Archives in Ontario. (Toronto, 1984).


 * National Archives of Canada. Manuscript Division. Health Sciences Guide. Finding Aid No. 1209 (Ottawa, 1987).


 * Public Archives of Canada. Union List of Manuscripts in Canadian Repositories. 2 v. (Ottawa:, 1975). Supplement 1976 (1976); Supplement 1977-78 (1979); Supplement 1979-80 (1982); Supplement 1981-82 (1985).


 * Registered Nurses Association of British Columbia. Survey of Nursing History Materials in British Columbia. (Vancouver, 1990).


 * Royal College of Physicians and Surgeons of Canada. Library and Archival Holdings in the Roddick Room. (Ottawa, 1978).


 * Spadoni, Carl. “Medical Archives: An Annotated Bibliography”. Archivaria 28 (Summer 1989): 74-119.


 * Weise, Frieda, ed. Health statistics: an annotated guide to information resources (Lanham, Md., 1996).


 * Wellcome Historical Medical Museum. Catalogue of an Exhibition Illustrating the Medicine of the Aboriginal Peoples in the British Commonwealth. (London, 1952).

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