Records and Access to Postgraduate Trainee Files

Approved PGME Committee - February 4th, 2021

Records & Access to Postgraduate Trainee Files Guidelines - [PDF-305k]

The following policy is to address access to resident files.

1. Purpose

As part of good educational and business practices, the Post Graduate Medical Education Office (PGME) and individual post graduate training programs are required to keep records (including virtual and/or hard copy) on Trainees. From time to time, access to Trainee files is required by individuals within or outside the University, as part of such processes as Trainee transfers, program accreditation, appeals, licensing or verification of training. At other times, Trainees seek access to their own files. All Trainee files are confidential. However, while confidential, not all parts of the Trainee’s file are “releasable” to the Trainee or 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 processes. This policy outlines the components of a Trainee’s files that are accessible by various parties and seeks to protect the privacy of the individual Trainee.

2. Application

This Policy applies to all Trainees who:
    a. have been accepted into or are currently enrolled into a program at    Dalhousie University
    b. have previously enrolled in a program at Dalhousie University.

3. Definitions

1. In this Policy:
    a. “Trainee” means a resident or fellow who has been accepted into or is enrolled in a Program, or who has been enrolled into the program.

4. Policy

1. Contents of Trainee Files
    a. The types of confidential information to be kept in a Trainee’s files is outlined in Appendix A of this policy.
    b. Appendix A outlines the types of confidential information which may be releasable under certain circumstances, and outlines information normally considered non-releasable unless there is a successful FOIPOP request or a legal requirement to release.

2. Security of Trainee Files
    a. Every trainee’s permanent paper-based PGME file must be kept in a locked, secured cabinet in the PGME office of the Faculty of Medicine.
    b. Every Trainee’s paper-based Program file must be kept in a locked, secured cabinet in a designated secure location within the applicable program office.
    c. All electronic records kept by the PGME office or the Training Program must be password protected and stored locally.

3. Retention of Trainee Files
    a. At the time of completion of training, or in the event of withdrawal or dismissal, a Trainee’s files will be placed in a secure digital environment and/or a physically locked storage environment by the Post Graduate Medical Education office and by the Program.
    b. Files will be kept for a total of 50 years from the completion of training, withdrawal, or dismissal.

4. Access by Trainee to Own Files
    a. Trainees have the right to reasonable access to the releasable elements of their own Trainee files. Reasonable access is defined as:
       (i) Access within 15 calendar days after a written request is received by the program administrator (for material held by the Program) or the PGME office staff (for material held by the PGME office) for Trainees currently enrolled in a training program.
       (ii) Access within 28 calendar days after a written request is received by the program administrator (for material held by the Program) or the PGME office staff (for material held by the PGME office) for Trainees who have completed, withdrawn from or been dismissed by a training program.
       (iii) Confidential, releasable files may be viewed by the Trainee in a private designated space within the program/department or PGME office. There is not a requirement for someone to remain with the Trainee while they are examining their file. Paper files must not be removed from the designated space.
       (iv) The Trainee may not add to the file or remove anything from the file, and the file must not be altered in any way while viewing. Copies can be requested of any releasable material (reasonable copy charges may be charged). However, the Trainee has the right to submit signed and dated documents with written comments to be added to the file.
       (v) A list of all documents that have been removed for the purposes of the review (if confidential and not releasable) will be provided to the Trainee.
    b. Trainees have access to their own evaluation and assessment documents through the on-line evaluation system. For assessments that are not part of the on-line system, a trainee can request copies from the Program Administrator.
    c. Copies of any documents that may result in, or arise from, disciplinary action must be provided immediately to the post graduate trainee concerned and entered into both the Program and PGME files.

5. Release of Information to Third Party Authorized by Trainee
    a. Trainees may also authorize release of portions of their Program or PGME files to other educational institutions, licensing authorities, or health care facilities for purposes of further education, licensure, or credentialing. Appendix A outlines the information that can be released with Trainee’s written authorization.
    b. Requests for release of information will generally be completed within 15 calendar days for current Trainees and 28 calendar days for Trainees who have completed, withdrawn from or been dismissed by a training program. Reasonable photocopy and transmission charges (fax, courier, mail) may apply, and the request may be held until payment is made.

6. Release/Use of Trainee’s Files for Other Educational Purposes
    a. As per Dalhousie University Regulations, “Information on students may be disclosed without the consent of the student to University Officials or committees deemed to have a legitimate educational interest”. (See Release of Information about Students)
    b. For purposes of this Policy, the following parties shall be deemed to have legitimate educational interest in Trainee files at all times:
       (i) A Program Director or Program Administrator for those Trainees registered in, have completed, or have withdrawn from or been dismissed from the Program for which they are responsible;
       (ii) Faculty members of a Residency Program Committee (RPC) for those Trainees currently registered in the program of the RPC. (Trainee members of an RPC may be deemed to have legitimate educational interest only upon approval of the Program Director or PGME Dean);
      (iii) Faculty members of a Competence Committee for those Trainees being reviewed by the committee;
      (iv) The PGME Dean, Assistant Dean or Administrative Assistants to these parties;
      (v) Accreditation survey teams approved by Dalhousie University shall be granted access to Trainee Files for the sole purpose of conducting an audit or review in connection with authorized institutional or program accreditation processes; and
     (vi) Other committees or officials may also be deemed by the PGME Dean to have legitimate educational interest as per the University Policy.

7. Other Requests for Access to Trainee Files
    a. Any other requests for information relating to files not expressly addressed in this Policy must be made to the University FOIPOP Coordinator as an access to information request. For a complete overview of the Dalhousie University access to information process please go to Dalhousie’s Legal Counsel Office website.
    b. Release of information to Third Parties is addressed in the University Regulation: Release of Information about Students that states the following in part:

Other than in the above situations, information on students will be released to third parties only at the written request of the student, or where the student has signed an agreement with a third party, one of the conditions of which is access to the student's record (e.g. in financial aid). This restriction applies to requests from parents, spouses, credit bureaus and police.

5. Administrative Structure
    1. Authority: This Policy is sponsored by and falls under the authority of the Dean of the Faculty Medicine.
    2. Postgraduate Medical Education: Postgraduate Medical Education is the unit responsible for the administration of this Policy.
    3. Policy Review: This Policy will be reviewed in accordance with Dalhousie’s Policy on Policies or earlier if deemed necessary by the Dean of the Faculty of Medicine.

6. Procedures
1. Additional procedures for implementation of this Policy may be developed as necessary.