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REPORTING REQUIREMENTS

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Approved by Council: November 2000
Reviewed and Updated: September 2004, April 2005, September 2005, June 2009, September 2012, October 2017, November 2024

 

Policies of the College of Physicians and Surgeons of Ontario (CPSO) set out expectations for the professional conduct of physicians practising in Ontario. Together with the Essentials of Medical Professionalism and relevant legislation and case law, they will be used by CPSO and its Committees when considering physician practice or conduct.

Within policies, the terms ‘must’ and ‘advised’ are used to articulate CPSO’s expectations. When ‘advised’ is used, it indicates that physicians can use reasonable discretion when applying this expectation to practice.

Additional information, general advice, and/or best practices can be found in companion resources, such as Advice to the Profession documents.

 

Policy

Physicians are required to report certain events or clinical conditions regarding their patients, other regulated health professionals, and themselves to CPSO, other health regulatory bodies (i.e., colleges), and designated agencies.

Depending on the circumstances, physicians may be required or permitted by law to make a report. Physicians may also be required by CPSO policy to notify an appropriate authority of specific information.

This policy outlines the professional expectations that have been set by CPSO with respect to reporting, and a list of the key reporting requirements that are set out in law can be found in the Guide to Legal Reporting Requirements companion resource.

General

  1. In addition to complying with the professional expectations contained in this policy, physicians must fulfill their legislative reporting requirements, which include those that are set out in CPSO’s Guide to Legal Reporting Requirements document.
  2. Unless doing so would pose a genuine risk of harm to themselves and/or others, physicians must notify patients about their duty to report at the earliest opportunity, and where possible, before making a report.
  3. When making a report about a patient, physicians must disclose only the information as required by law or necessary to address the risk of harm.
  4. While most legislative reports must be made within a specified period of time, where a timeline is not set out in law, physicians must file a report in a timely manner once a requirement to report arises.

Incompetence and Incapacity

  1. While facility operators are legally required to report concerns of incapacity and incompetence, all physicians must take appropriate and timely action when they have reasonable grounds to believe that another physician or regulated health professional is incapacitated or incompetent, including circumstances where the individual’s pattern of care, physical or mental health, or behaviour poses a likely risk of injury or harm to patients.

Documentation

  1. Physicians must capture in the medical record relevant details of any report made about a patient (e.g., including a copy of the report made to the Ministry of Transportation in the patient’s medical record).

Endnotes

  1. Some laws allow (but do not require) physicians to make a report even if it means disclosing confidential patient information.

  2. This includes harm that may result to the physician, the physician’s staff, the patient, etc.

  3. For more information on when to notify patients of a duty to report see the Advice to the Profession: Reporting Requirements.

  4. What constitutes “timely” will depend on the circumstances of each case, including the level and nature of the risk inherent in the situation. 

  5. For more information on facility operators see the Guide to Legal Reporting Requirements.

  6. “Incapacitated” means that a regulated health professional is suffering from a physical or mental condition or disorder that makes it desirable in the interest of the public that their certificate of registration be subject to terms, conditions, or limitations, or that they no longer be permitted to practise. 

    See s. 1(1) of the Health Professions Procedural Code, Schedule 2 of the Regulated Health Professions Act, 1991, S.O. 1001, c.18 (“HPPC”).

  7. “Incompetent” means that a regulated health professional’s care of a patient displayed a lack of knowledge, skill, or judgment of a nature or to an extent that demonstrates that they are unfit to continue to practise or that their practice should be restricted. See s. 52(1) of the HPPC.

  8. For more information on how to take “appropriate and timely” action see the Advice to the Profession: Reporting Requirements.

  9. For more information on the details that must be captured in the patient record see the Advice to the Profession: Reporting Requirements.