# 2019-209 Medical and Dental Care, Medical Record

Case summary

F&R Date: 2020-08-31

The grievor argued that inaccurate and incomplete information in his medical file affected his ability to pursue career opportunities. The grievor requested that a complete review of his medical file be conducted and all incorrect medical entries be redacted, corrected, or annotated in his health records.

The Commander, Canadian Forces Health Services Group, acting as the Initial Authority (IA), found that that the grievor was treated fairly and in accordance with applicable policies. The IA did not grant redress.

The Committee found that the refusal to correct the grievor's self-reported information or the opinions and observations of health care professionals in his medical file was policy compliant. The Committee also found that the grievor's medical file should be annotated to reflect the refusal to correct entries disputed by the grievor in accordance with Canadian Forces Health Services Instruction (CF H Svcs Instr) 7000-11.

The Committee found that there were factually inaccurate references in the grievor's medical file that required correction or annotation.

The Committee recommended that the Final Authority (FA) afford the grievor partial redress by providing him with the opportunity to present a detailed list of disputed entries in his medical file that can be annotated to reflect that a correction was requested but refused.

The Committee also recommended that the FA direct that the inaccurate information in the grievor's medical file be corrected or annotated in accordance with the CF H Svcs Instr 7000-11.

FA decision summary

The Final Authority (FA), the Director Canadian Forces Grievance Authority, agreed with the Committee's recommendation to partially grant redress by annotating the grievor's medical records to reflect that they contained a factual error, as demonstrated by the evidence submitted, and by directing the Commanding Officer of the appropriate Canadian Forces Health Service Centre to facilitate the annotation of the grievor's file to indicate entries that were not considered errors, but with which the grievor disagreed, in accordance with the relevant policy.