Laws regarding promptly updating medical records
The policy indicates any additional requirements that exist based on the type of record (e.g., paper, electronic or hospital-based records) or the physician’s practice (e.g., primary care, procedural medicine, group practice).The purpose of this policy is to set out physicians’ professional and legal obligations with regard to medical records and to provide all practising physicians with a tool that will assist them in implementing record-keeping practices that are practical and easy to maintain.It is a living document that tells the story of the patient and facilitates each encounter they have with health professionals involved in their care.In addition to telling the patient’s story, complete and accurate medical records will meet all legal, regulatory and auditing requirements.Policy Number:#4-12 Policy Category: Administrative Under Review: No Approved by Council: November 2000 Reviewed and Updated: September 2005, November 2006, May 2012 College Contact: Physician Advisory Service Downloadable Version(s): Medical Records The medical record is a powerful tool that allows the treating physician to track the patient’s medical history and identify problems or patterns that may help determine the course of health care.
Most importantly, however, they will contribute to comprehensive and high quality care for patients by optimizing the use of resources, improving efficiency and coordination in team-based and interprofessional settings, and facilitating research.This is achieved in the following ways: This policy explains how medical records must be kept, outlining general requirements and considerations about the collection, use, storage, and disclosure of patients’ personal health information, with respect to both paper and electronic records.Physicians are ultimately responsible for meeting the expectations set out in this policy and may assess their own medical record-keeping practices by answering the questions listed in Appendix C, which have been taken directly from a protocol used in the College’s peer assessment activities.This policy establishes principles and requirements for all medical records and applies to all physicians.
In accordance with The Practice Guide, the professional expectations in this policy are based on the following principles: The College expects all physicians to keep medical records that are consistent with their legal obligations and the expectations set out in this policy.
While many of the elements of the guidance set out below are mandatory, other components of the policy are offered as recommendations as to the best means of providing patients with quality medical care.