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G.4.3 Confidentiality of Records and Documents


Paramedic Services Effective Date: April 30, 2022
Topic: Documentation Directives Replaces: April 30, 2019
Subject: Confidentiality of Records and Documents Policy No. G.4.3.



The Personal Health Information Protection Act, 2004 (PHIPA) is health specific privacy legislation. It governs the manner in which personal health information may be collected, used, disclosed and retained. Manitoulin-Sudbury DSB personnel are considered confidential health information custodians and must follow all legislative requirements pertaining to the securing of patient information. Paramedic Services and all staff will ensure safeguards are in place to protect personal health information as per legislation.

  • Paramedics
  • Paramedic Superintendents
  • Senior Managers
  • Administrative Staff

The security of patient records and personal health information are captured in legislation, and failure to ensure such security puts patient privacy at risk. Additionally, failure to secure such information jeopardizes the organisation and Paramedic standing as a patient advocate.   


Technical safeguards to protect DSB computers, used by Paramedics to record patient information include:

  • The locking screens when computers are unattended.
  • The implementation of a unique login and password for each user, and the logging of user activity. 
  • Where breaches of PHIPA are met, such as the inappropriate use, disclosure, or access of personal health information, disciplinary action will be taken up to and including termination of employment and notifying any relevant regulatory bodies and/or professional associations. 

Physical Safeguards to protect the computers which are used by Paramedics to record patient chart include:

  • Locking ambulance at all times.
  • Locking ambulance station at all times with secure code access.
  • Regular assessments by the employer to ensure safeguards are in place and functional.

Access to the records, forms or other Paramedic Service documentation pertaining to any response shall be granted only as per PHIPA legislation.  All records will be properly secured for a minimum of five (5) years.
All information relating to any phase of Paramedic response or transportation is confidential and shall not be released by staff to the public, media and/or allied agency.
Any transmission of information relating to any call for Paramedic Services on any social media platform, secure or not secured, is strictly prohibited.
Any internal or external inquiries regarding the actual Paramedic response shall be directed to the Deputy Chief’s office.
General inquiries regarding ambulance bookings shall be directed to CACC.
Any request for specific information shall be handled as follows:

a) obtain name and phone number of the person making the inquiry;
b) the date and time the inquiry was made;
c) the date and time the incident occurred;
d) advise the person making the request that Management will return their call during normal business hours;
e) Immediately advise the on-duty Superintendent of the request and complete any additional documentation required. Should the Superintendent not be available, the Deputy Chief shall be advised of the request.

  1. Management is to be notified upon the arrival of any Ministry of Health (MOH) official. (e.g. - Inspector, Paramedic Superintendent, CACC Manager, etc.)
  2. Proper identification is required from any MOH Official/Inspector wishing to examine the Paramedic Services fleet, equipment or facilities, or any documents related to the Service. Should this identification not be provided and verified, access will be denied until Deputy Chief approval is received.
  3. Upon receipt of satisfactory identification, all reasonable cooperation shall be given by Paramedic Services personnel to MOH Inspectors.

Personal Health Information Protection ACT, 2004, S.O. 2004, c.3. Sched. A

Ministry of Health, Emergency Services Branch, Documentation Standards, The 
Crown in Right of the Province of Ontario

Ministry of Health, Emergency Services Branch, ACR Completion Manual, The 
Crown in Right of the Province of Ontario