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- Physicians are required by the Medical Records Documentation policy to document their patient encounters as soon as possible. In keeping with this requirement, it is important to dictate or transcribe operative and procedural notes on the day on which the procedure took place, or where this is not feasible, as soon as possible after the procedure.
www.cpso.on.ca/en/Physicians/Policies-Guidance/Policies/Medical-Records-Documentation/Advice-to-the-Profession-Medical-Records-Documenta
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Do physicians have to make records for each patient?
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Do physicians have to record a patient encounter?
What information should be included in a medical record?
Are physicians always the custodians of patient medical records?
Physicians must ensure medical records are retained for a minimum of the following time periods 28: Adult patients: 10 years from the date of the last entry in the record. Patients who are children: 10 years after the day on which the patient reached or would have reached 18 years of age. 29, 30.
Section 18(1) paragraphs 1 and 2 of the Medicine Act, General Regulation require physicians to make records for each patient containing the patient’s name, address, date of birth and Ontario health number, where applicable.
Physicians should access information in a medical record only for clinical reasons and while they are a member of the patient’s circle of care. Patients have a right to access their personal health information in their record at any time and for any reason, subject to certain exceptions (e.g. if there is likelihood of harm to the patient).
As required by the Medical Records Management policy, physicians must do everything reasonably within their control to prevent disputes about records from impacting patient care. Written agreements regarding medical records can provide assurance that the expectations of the policy are being met.
Patients own the information in their medical records and are entitled to examine and/or receive a copy of their medical record upon request, which includes any records created by other registrants.
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In a solo office practice, the physician is the custodian and therefore controls access to medical records. The physician has a duty to protect patients’ privacy and maintain the confidentiality of patients’ personal information. These obligations also extend to a physician’s office staff.
requirements related to medical record documentation: Requirements for medical practice records 3-5 (1) A registrant must (a) keep records in English, (b) keep a clinical record on each patient containing (i) the patient’s name, gender, personal health number, date of birth, address and dates of attendance,
