PHIPA DECISION 318

Complaint HA24-00174

Vision Group

December 15, 2025

Summary: The complainant made a follow-up request to the custodian to correct records containing his personal health information related to an eye procedure. He complained to the IPC about the custodian’s refusal to make certain corrections to the records.

The adjudicator determines that no review is warranted under sections 57(3) and 57(4)(a) of the Act because there are no reasonable grounds to review the complaint as the custodian has responded adequately to the complaint. The complaint is dismissed.

Statutes Considered: Personal Health Information Protection Act, 2004,  S.O. 2004, c 3, Sched A, sections 3(1) , 4(1) , 55(1) , (8) , (11) , 57(3)  and (4) .

Related Decision: PHIPA Decision 317.

BACKGROUND:

[1] This decision addresses a complainant’s follow-up request to correct records of his personal health information (PHI) under the Personal Health Information Protection Act (the Act or PHIPA) to Vision Group (the custodian).[1] In this request, the complainant asked the custodian to make eight corrections to medical records related to an eye procedure.[2] The complainant says the procedure resulted in an over-correction which negatively impacted his eyesight. He says that the information he has requested to be corrected in the records would better reflect what occurred and would ensure that future caregivers have accurate information.

[2] The first correction request asked the custodian to reconcile differences the complainant says is contained in a pre-op report.[3] The custodian’s correction decision denied the request saying that the pre-op details were updated on the day of surgery to include the measurements requested by the doctor.

[3] The second correction request asked the custodian to change the percentage number noted regarding his use of contacts and glasses.[4] The custodian’s correction decision denied the request citing section 55(8) taking the position that the record is not incomplete or inaccurate for which it uses the information.

[4] The third correction request asked the custodian to adjust a number recording a depth measurement in the pre-op record.[5] The custodian’s correction decision denied the request taking the position that the information the complainant seeks to correct is the doctor’s professional opinion or observation.

[5] The fourth correction request asked the custodian to correct information in the treatment report as to whether an astigmatism was recorded.[6] The custodian’s correction decision denied the request taking the position that the information the complainant seeks to correct is a professional opinion or observation.

[6] The fifth correction request asked the custodian to adjust a reading in a post op report alleging that it was not taken properly.[7] The custodian’s correction decision denied the request stating that the measurement was taken using precise equipment.

[7] The sixth correction request asked the custodian to add a notation in the post op report and change a notation recording his satisfaction.[8] The custodian’s correction decision denied the request taking the position that the information the complainant seeks to correct is a professional opinion or observation.

[8] The seventh correction request asked the custodian to add notations to a post op report.[9] The custodian’s correction decision denied the requests citing section 55(8) taking the position that the record is not incomplete or inaccurate for which it uses the information.

[9] The eighth correction request asked the custodian to add notations to a post op report[10]. The custodian’s correction decision denied the requests citing section 55(8) taking the position that the record is not incomplete or inaccurate for which it uses the information.

[10] In response, the complainant filed a complaint with the Information and Privacy Commission of Ontario (IPC) and a mediator was assigned to explore settlement with the parties.

[11] During mediation, the custodian confirmed that it relies on section 55(9)(b) of the Act to support its decision to deny the complainant’s correction request on the basis that the information constitutes a professional opinion or observation. The custodian also confirmed it continues to rely on section 55(8) to deny the correction request. The complainant told the mediator that he had an audio recording which he says supports his request for correction. The complainant subsequently shared with the mediator, a copy of the recording along with a written explanation.

[12] The custodian confirmed with the mediator that it considered the complainant’s additional evidence but it continued to take the position that it is not required to grant the complainant’s follow-up correction requests.

[13] The mediator’s report also identified another issue the complainant raised during mediation[11]. The complainant had questions about the existence of two versions of the September 20^th pre-op record.

[14] Mediation did not resolve the complaint and the file was transferred to the adjudication stage of the complaint process in which an adjudicator may decide to conduct a review.

[15] After reading the complaint file, I wrote to the complainant advising him of my preliminary assessment that his complaint should not proceed to the review stage. The complainant was invited to provide written representation in response to my preliminary assessment before I made my final decision. The complainant submitted written representations in response.

[16] In this decision, I find that the complaint should not proceed to a review under the Act because there are no reasonable grounds to conduct a review (section 57(3)) and the custodian has responded adequately to the complaint (57(4)(a)).

DISCUSSION:

Should the complaint proceed to a review under the Act?

[17] Sections 57(3) and 57(4)(a) of the Act set out the IPC’s authority to review or not to review a complaint. These sections state:

(3) If the Commissioner does not take an action described in clause (1) (b) or (c) or if the Commissioner takes an action described in one of those clauses but no settlement is effected within the time period specified, the Commissioner may review the subject-matter of a complaint made under this Act if satisfied that there are reasonable grounds to do so.

(4) The Commissioner may decide not to review the subject-matter of the complaint for whatever reason the Commissioner considers proper, including if satisfied that,

(a) the person about which the complaint is made has responded adequately to the complaint;

[18] After reading the complainant’s written representations along with the contents of the complaint file which included the audio recording and written statement the appellant shared during mediation, I exercise my discretion not to review the subject-matter of this complaint finding that there are no reasonable grounds to conduct a review. I am also satisfied that the custodian has responded adequately to the complaint. I explain my reasons below.[12]

There is no useful purpose served by a review of the complaint about the hospital’s refusal to correct

[19] Section 55(1) of the Act sets out the right of an individual to request a correction to records of the individual’s personal health information. This section states:

If a health information custodian has granted an individual access to a record of his or her personal health information and if the individual believes that the record is inaccurate or incomplete for the purposes for which the custodian has collected, uses or has used the information, the individual may request in writing that the custodian correct the record.

[20] Section 55(8) sets out a duty on the part of a health information custodian to grant a request for correction where certain conditions are met. This section states:

The health information custodian shall grant a request for a correction under subsection (1) if the individual demonstrates, to the satisfaction of the custodian, that the record is incomplete or inaccurate for the purposes for which the custodian uses the information and gives the custodian the information necessary to enable the custodian to correct the record.

[21] If the requirements of section 55(8) are established, the question becomes whether or not any of the exceptions that are set out in section 55(9) apply. In the circumstances of this complaint, the custodian claims that the exception at section 55(9)(b) applies. This section states:

Despite subsection (8), a health information custodian is not required to correct a record of personal health information if, it consists of a professional opinion or observation that a custodian has made in good faith about the individual.

The complainant has not discharged the onus in section 55(8)

[22] In all cases where a complaint regarding a custodian’s refusal to correct records of personal health information (PHI) is filed with the IPC, the individual seeking the correction has the onus of establishing that the “record is incomplete or inaccurate for the purposes for which the custodian uses the information” pursuant to section 55(8).

[23] Section 55(8) requires the individual asking for correction to:

1. demonstrate to the satisfaction of the custodian, that the record is incomplete or inaccurate for the purposes for which the custodian uses the information, and
2. give the custodian the information necessary to enable the custodian to correct the record.

[24] If the above is established, the question becomes whether or not any of the exceptions that are set out in section 55(9) apply. Accordingly, before I consider the custodian’s claim that portions of the records contain its professional observations or opinion, I must first determine whether the complainant has discharged the onus in section 55(8).

[25] Previous IPC decisions have found that not all PHI contained in records held by health information custodians needs to be accurate in every respect. If a request is made to correct inconsequential bits of information that have no impact on the purposes for which the custodian uses the information, and the custodian is not relying on the information for a purpose relevant to the accuracy of the information, the custodian is not required to correct the information.[13]

[26] In addition, the IPC has found that the custodian is not required to grant the correction request if the individual seeking the correction does not provide the custodian with the information necessary to enable it to correct the record.[14]

[27] As noted above, the complainant seeks the following corrections to the medical records:

• Reconcile the data differences he says appears on the same page provided to him at different times (first correction request),
• Change the percentage number reported in the records regarding his use of contacts and glasses (second correction request),
• Adjust the number recording a depth measurement (third correction request),
• Correct information as to whether an astigmatism was recorded (fourth correction request),
• Adjust a reading he says was not taken properly (fifth correction request),
• Add a notation in the records recording his eyesight after the procedure and his satisfaction level of the procedure (sixth correction request),
• Add a notation regarding the reflective level reported in the record (seventh correction request), and
• Add notations regarding information he says the custodian told him after the procedure was performed (eighth correction request).

[28] The complainant says the notations and measurements he has requested be corrected are inaccurate for the purpose for which the custodian uses the information “namely, determining surgical eligibility, documenting clinical assessments, supporting quality assurance and potentially defending clinical decisions or outcomes post hoc.” For example, the complainant says that the information in the record “misrepresents” his actual vision habits and “could be used to justify or minimize the significance of a poor surgical outcome.” The complainant goes on to state:

… misrepresenting that I wore glasses 90% of the time could be cited to argue that a post operative full-time reliance on glasses after surgery is consistent with my baseline – even though I only wore them around 9% of the time prior to surgery. This type of misrepresentation undermines both clinical accountability and the integrity of any future assessment of harm.

[29] Attached to the complainant’s representations was a medical opinion he obtained from an Ophthalmologist. I note that that this individual refers to himself, in the documentation provided by the complainant, as a medical expert witness in Ophthalmology. I have reviewed the opinion and note that the expert indicated that a procedural miscalculation or planning error related to reflective readings could explain the vision deterioration the complainant says he experienced after the procedure. The complainant says that he is seeking corrections to rectify missing or incorrect reflective readings in the records. The complainant also referenced two articles to demonstrate the importance of monitoring reflective measurements following the type of procedure he had.

[30] Having read and considered the entire complaint file, including the written representations the complainant submitted in response to my preliminary decision, I find that the complainant’s evidence fails to establish a reasonable basis that the information he seeks to be corrected in the records is “incomplete or inaccurate for the purposes for which the custodian uses the information” as required by section 55(8) of the Act.

[31] I maintain my view, expressed in the preliminary assessment, that corrections sought by the complainant are not relevant for the purpose for which the custodian uses the information. The wording in section 55(8) is clear. The individual seeking the correction has the onus of establishing whether or not the “record is incomplete or inaccurate for the purposes for which the custodian uses the information”.

[32] The accuracy of the information that is requested to be corrected is connected to the purposes for which the information is used by the custodian.[15] Here, the custodian’s use of the records is to document the health care and services it says it provided to the complainant. The complainant says that the information in the records is missing important measurements or fails to explain the surgical outcome he experienced. In my view, the complainant’s evidence describes his use of the records. Namely, his pursuit of a legal remedy to address the vision loss he says he experienced after the procedure.

[33] As I stated in PHIPA Decision 317, the health provider’s use of a record need not mirror the patient’s use. In fact, the Act contemplates different uses or purposes and requires health providers to add a statement of disagreement to any record in its custody which contains the PHI of a patient.

[34] As stated above, the custodian has already attached the complainant’s statements of disagreement to the records.

[35] Having regard to the purpose of the records along with the complainant’s evidence, I find no reasonable basis to support a finding that the complainant has discharged the onus in section 55(8). Accordingly, I find the custodian does not have a duty to correct the records under section 55(8).

[36] Given my finding, it is not necessary that I determine whether the complainant gave the custodian the information necessary to enable it to correct the records. It is also not necessary that I determine whether the professional opinion or observation made in good faith exception at section 55(9)(b) applies.

Other Issue:

[37] As noted above, the complainant raised questions about the existence of two versions of the September 20^th pre-op record.[16] In his representations, the complainant says he is unsatisfied with the custodian’s response to the concerns about this report he raised during mediation.

[38] The complainant says that more than one version of this record was provided to him. The explanation the custodian provided during mediation is that the difference between the two versions is the result of its Electronic Medical Records system (EMR) automatically performing an update and an administrative error.

[39] In his representations, the complainant appears to take the position that this record should only contain pre-operation notations. He says that merging pre and post-operative notations in one record “undermines the credibility of the record-keeping process.”

[40] The complainant also says in his representations that “[e]ven accepting that ‘Pre-op combined’ documents are system-generated for clinical convenience, the custodian has not explained”:

Why data referencing an October procedure appeared under a September appointment heading,

Why the document’s title did not clearly denote it as a hybrid or merged record [and,]

Why this specific document was included in earlier disclosures and then silently omitted from later ones.[17]

[41] The complainant says that the existence of different versions of this record and the disappearance from subsequent disclosures “speak to a deeper issue with record integrity, accountability, and the adequacy of the custodian’s handling of [personal health information].”

[42] The complainant goes on to state:

The removal of this document, without notation, justification, or acknowledgement, may constitute a serious violation of [section 55(10) of the Act]. Whether this omission was deliberate or accidental, it demonstrates a failure to preserve the integrity and auditability of the record trail – a foundational requirement under health information law.

Preserving the history of the record is essential to allow independent scrutiny of discrepancies – such as the differential between the two versions of the September 20 record. Even if a patient retains the original version, they may lack the medical expertise to interpret the differences, and it would be inappropriate for them to speculate on their own. This makes it all the more important that prior versions are transparently maintained by the custodian. The disappearance of this record needs to be addressed before other issues can be fully considered, as it may provide important context for resolving additional ambiguities in the overall documentation.

…

The custodian’s claim that “only one existing version of the medical record” remains raises further concerns. It implies that prior iterations – including the version I originally received – have been overwritten, deleted, or otherwise not preserved. If true, this would contradict the requirement under PHIPA to maintain a clear and transparent record of any correction, disputed or replaced health information.

Even if the [current] version reflects an “updated” record, that does not justify retroactively eliminating a previously disclosed, different version.

[43] The complainant references section 55(10) of the Act.[18] This provision provides guidance in how custodians are to make corrections to records of PHI. The requirements such as striking out incorrect information in a manner that does not obliterate the record or storing separately incorrect information removed from a record occur in situations where the custodian has granted a request for correction under section 55(1). That is not the situation here.

[44] The situation before me is that the complainant says that he has received two different versions of a record entitled “Pre-Op Detail (Appointment: 20-September).” The complainant takes the position that this record should not have been updated to include information gathered on October 11^th. The complainant says that the Act requires the custodian to maintain separate records for the September 20^th and October 11^th appointments and that if they are merged the requirements in section 55(10) should be adhered to.

[45] The complainant’s arguments also appear to allege that the type of “loss” contemplated in section 12 took place. The loss being that the custodian no longer has a copy of the original version of the pre-op detail that does not reference information gathered on October 11^th. Section 12 states:

A health information custodian shall take steps that are reasonable in the circumstances to ensure that personal health information in the custodian’s custody or control is protected against theft, loss and unauthorized use or disclosure and to ensure that the records containing the information are protected against unauthorized copying, modification or disposal.

[46] I have considered the complainant’s submissions and find that evidence of an updated electronic medical record alone fails to establish that the custodian in the circumstances of this complaint contravened sections 12 or 55(10) of the Act. One, no loss occurred. The electronic record was updated when the custodian added a notation to the record. Two, section 55(10) does not provide guidance on general record keeping practices. This section only applies to situations in which the custodian has granted a correction request. The College of Physician and Surgeons (CPSO) publishes medical records management policies which sets out its expectations for physicians with custody or control of medical records. I am not aware of any requirement under the Act that requires the custodian to maintain the pre-op record in the manner suggested by the complainant.

[47] Having regard to the above, I find that there are no reasonable grounds to review the complainant’s concerns related to having received two versions of the September 20^th pre-op record. In any event, the custodian provided an explanation in response to the complainant’s concerns about this record during mediation.

Summary

[48] I exercise my discretion not to review the subject-matter of this complaint finding that there are no reasonable grounds to conduct a review (section 57(3)). In addition, I am satisfied that the custodian responded adequately to the correction request related to this complaint (57(4)(a)). In this regard, I note that the custodian provided the complainant with an explanation where it determined it was not required to make the requested correction under the Act.

[49] For the reasons set out above, I dismiss the complaint.

NO REVIEW:

For the foregoing reasons, no review of this matter will be conducted under Part VI of the Act.

Original Signed by:		December 15, 2025
Jennifer James
Adjudicator