Across the healthcare landscape, the accuracy and completeness of patient records are critical. It helps ensure the delivery of safe care, continuity of treatment, and respect for individual rights in accordance with privacy law.
This is particularly true for dentists, who are designated as custodians of health information under Ontario’s Personal Health Information Protection Act, 2004 (“PHIPA“).
A recent decision of the Information and Privacy Commissioner of Ontario (IPC) – Parkview Oral and Maxillofacial Surgery – involving a dentist provides a useful case study on how obligations to maintain records collide with correction requests from patients.
In what follows, I unpack the obligations of a dentist-custodian, the facts of this case (including issues of inaccuracy and incompleteness), the legal carve-out for “professional opinion made in good faith,” including burden of proof considerations, and conclude with best-practice takeaways for record-keeping.
Dentists as Custodians of Health Information
Under PHIPA, a regulated health professional who “collects, uses or discloses” personal health information in the course of providing care is generally a “health information custodian” (HIC). A dentist practising in Ontario, therefore, has several obligations:
- Collect, use or disclose only the minimum personal health information necessary for the purposes of providing care.
- Create and maintain accurate and complete records of the information collected and used for the purpose of providing care. PHIPA mandates that custodians ensure the records are “complete and accurate for the purposes for which the custodian uses the information.”
- Ensure that appropriate administrative, technical, and physical safeguards are in place to protect the privacy of personal health information under their custody or control.
- Enable individuals (patients) to request access and, if appropriate, correction of their personal health information.
- Respond within prescribed timeframes (usually 30 calendar days) to access and correction requests, unless extended for good reason.
For a dentist, this means the dental record—notes of examinations, diagnoses, proposed treatments, radiographs, communication with other providers, consent documents and follow-up plans—must be responsibly maintained, and when necessary, amended or supplemented. Failure to do so can lead to investigations, complaints and costly adjudications.
The Case: Dentist’s Records Alleged Inaccurate and Incomplete
Let’s turn now to the case of Parkview Oral and Maxillofacial Surgery (Re). Here, the IPC decision involved a dentist-custodian and a patient claiming that their dental records were inaccurate and incomplete. The patient requested a correction to her dental record, but the dentist refused.
Specifically:
- The patient complained that the dentist told her that antibiotics were used during a procedure, but the records don’t list any antibiotics.
- The patient complained that the dentist told her that fragments of tooth 36 were luxated and removed, but tooth 36 came out in one piece with no fractures or cracks.
- The patient complained that the dentist did not mention in their records that root canal substance was still present at the extraction site, despite her having complained about it to the dentist.
The patient argued that it’s important to have an accurate patient file to ensure proper diagnosis when she sees medical professionals in the future for her ongoing issues with the site of the extraction.
The dentist, however, denied that the record was inaccurate or incomplete, on the basis that the entries represented his professional opinion and were made in good faith. The IPC decision analyzed whether the dentist had a duty under PHIPA section 55(8) (the correction provision) to update the records.
The Dentist’s Defence: “Professional Opinion Made in Good Faith” Exception
Under PHIPA, section 55(8) gives an individual the right to request correction if they believe a record is inaccurate or incomplete for the purposes for which the custodian uses the information. However, section 55(9)(b) provides an exception: a custodian is not required to correct a record if it “consists of a professional opinion or observation that a custodian has made in good faith about the individual.”
Thus, the legal principle is clear: even if a patient believes the record is factually wrong (which it may very well be), if the entry is properly classified as a professional opinion/observation, and was made in good faith, the custodian is not required to amend it. The patient may instead request a statement of disagreement be attached (which is allowed under section 55(11)).
Onus and Burden of Proof: Who Must Prove What?
The allocation of burden is critical. Once a patient requests correction, the first step is to determine whether the patient has demonstrated that the record is inaccurate or incomplete for the purposes for which the custodian uses it (i.e., section 55(8)). If the patient clears that hurdle, then the custodian may invoke the exception under section 55(9)(b). At that juncture:
- The custodian must prove that the entry is a professional opinion or observation.
- Once established, the onus shifts to the patient to demonstrate that the opinion or observation was not made in good faith (e.g., showing malice, intent to harm, or serious carelessness/ recklessness).
In the dentist case, the patient could not provide sufficient evidence of bad faith. The patient tried to complain that the dentist seems to maintain “his position out of spite, pride, and his conflict of interest relationship with [another dentist].” But none of this was enough to prove to the IPC that the records were not made in good faith. There just wasn’t enough evidence presented by the patient to demonstrate a lack of good faith on the dentist’s part. Accordingly, the exception applied and the correction request was denied. The IPC noted, however, that the patient could still submit a statement of disagreement and have it attached to her records.
Good Record-Keeping Is Essential—Don’t Wait Until a Complaint!
What does this case teach dentists and other custodians of health information?
First, build your records with care: ensure they are comprehensive, contemporaneous, accurate, clear (both factual items and where you are recording your professional assessment), and are supported by objective findings, patient-reported symptoms, informed-consent discussions, and follow-up plans. Make sure you document the patient’s communications (symptoms, concerns, preferences) as well as your observations and professional opinion.
Second, when drafting treatment plans or noting “required” procedures, be explicit about your clinical rationale, assessment, discussion with the patient (including alternative options), and the standard of care. That way, your entries are more clearly grounded in professional judgement and less vulnerable to being framed as purely factual statements subject to challenge.
Third, when a patient requests a correction, treat it seriously. Review whether the record is factually inaccurate or incomplete in the sense relevant to the use of the information. If so, make the change and update the record in a way that maintains audit-trail integrity (note: PHIPA requires striking out incorrectly entered information, annotating corrections, and not obliterating).
Fourth, if you believe the entry is a professional opinion/observation made in good faith and you choose to exercise your right to refuse correction under section 55(9)(b), ensure you provide written notice of your refusal, your reason (that the entry is professional judgement made in good faith), and you can mention the patient’s right to attach a statement of disagreement. Document that you considered the request carefully.
Finally, recognize the cost of complaints. The case before the IPC took considerable time; investigations, mediation, submissions and adjudication were required before resolution. For a dentist, the time, stress, legal costs, reputational risk, and administrative burden of responding to a complaint are non-trivial. Good record-keeping, good communication with patients, and a robust internal policy for responding to correction requests will help to prevent escalation.
Bottom Line
Yes, when a patient requests a correction, you must evaluate carefully whether you need to correct inaccurate or incomplete factual data. But you also have a legitimate defence where the entry reflects your professional opinion or observation made in good faith. The key is to be proactive—keep excellent records now so you’re not playing catch-up later.
