Medical Records Documentation

Approved by Council: November 2000
Reviewed and Updated: September 2005, November 2006, May 2012, March 2020
Companion Resources: Advice to the Profession

Other references: Advice to the Profession: AI Scribes in Clinical Practice

Definitions

Cumulative Patient Profile (CPP) or equivalent patient health summary: A summary of essential information about a patient that includes critical elements of the patient’s medical history and allows the treating physician, and other health care professionals using the medical record, to quickly get a picture of the patient’s overall health.

Policy

1. Physicians must comply with all relevant legislation¹ and regulatory requirements related to medical record-keeping².

Principles for Documenting the Patient Encounter

2. The goal of the medical record is to “tell the story” of the patient’s health care journey. As such, physicians’ documentation in the medical record must be:
   1. legible;³
   2. understandable to health care professionals reading the record, including avoiding the use of abbreviations that are known to have more than one meaning in a clinical setting or that are not commonly used or understood;
   3. accurate;⁴
   4. complete and comprehensive, containing:
      1. all relevant information;
      2. information that conveys the patient’s health status and concerns;
      3. any pertinent details that may be useful to the physician or future health care professionals who may see the patient or review the medical record; and
      4. documentation that supports the treatment or procedure provided (i.e., rationale for the treatment or procedure is evident in the record);
   5. unique to each patient encounter (e.g., refraining from inappropriate use of copy and paste);
   6. identifiable, containing a signature or audit trail that identifies the author;
   7. written in either English or French; and
   8. organized in a chronological and systematic manner⁵.
3. Physicians must ensure their documentation in the medical record is professional and non-discriminatory, and in accordance with the College’s Human Rights in the Provision of Health Services policy.⁶

Timing of Documentation

4. To support the safe delivery of care, physicians must document their patient encounters as soon as possible.^{7, 8}

Use of Templates

5. The use of electronic record templates, particularly those with pre-populated fields, poses risks to accurate and complete medical records. In keeping with the requirements of accuracy and completeness set out in 2(c) and 2(d) above, physicians who use templates must:
   1. only use templates that allow patient encounters to be captured accurately and comprehensively (e.g., templates that allow entry of free-text or that can be customized to allow for greater descriptive detail); and
   2. verify that the entries populated using a template accurately reflect each patient encounter and that all pertinent details about the patient’s health status have been captured.⁹

What to Document: Medical Records Content

6. Physicians must ensure that patient identification (i.e., name, date of birth, OHIP number, gender information) and contact information (i.e., telephone number and address) are captured in all medical records.¹⁰
7. Physicians must date each entry in the medical record. Where the date of the patient encounter differs from the date of documentation, physicians must record both dates.¹¹

CPP or Equivalent Patient Health Summary

8. Primary care physicians must include an easily accessible, accurate, and up to date CPP, or an equivalent patient health summary, in each patient medical record, which includes the following, where applicable:
   1. patient identification;
   2. patient contact information;
   3. personal and family data (e.g., occupation, life events, habits, family medical history);
   4. past medical history (e.g., past serious illnesses, operations, accidents, genetic history);
   5. risk factors;
   6. allergies and drug reactions;
   7. ongoing health conditions (e.g., problems, diagnoses, date of onset);
   8. health maintenance (e.g., periodic health exams, immunizations, disease surveillance);
   9. names of any consultants involved in the patient’s care;
   10. long-term management needs (e.g., current medication, dosage, frequency);
   11. major investigations;
   12. date the CPP was last updated; and
   13. contact person in case of emergencies.
9. All other physicians must use their professional judgement to determine whether to include a CPP or an equivalent patient health summary in each patient medical record, considering a variety of factors, such as the nature of the physician-patient relationship (e.g., whether it is a sustained physician-patient relationship¹²), the nature of the care being provided, and whether the CPP or equivalent summary would reasonably contribute to quality care.¹³

Clinical Notes

10. Physicians must document the following for all patient encounters, where indicated:
    1. presenting complaint;
    2. a focused relevant history;
    3. an assessment and an appropriate focused examination;
    4. a diagnosis and/or differential diagnosis;
    5. any treatment or therapy provided and the patient’s response and outcomes; and
    6. a management and follow-up plan, including advice given to patients and/or care givers.
11. Physicians must capture details of the following in each patient medical record:
    1. any prescriptions issued in accordance with the College’s Prescribing Drugs policy;
    2. consent in accordance with the College’s Consent to Treatment policy and any consent to treatment obtained in writing;
    3. all tests requisitioned and referrals made¹⁴, including a copy of the referral note, and any associated reports and results (e.g., laboratory, diagnostic, pathology);¹⁵
    4. any treatments, investigations, or referrals that have been declined or deferred, the reason, if any, given by the patient, and discussion of the risks;
    5. any operative and procedural records;¹⁶ and
    6. any discharge summaries.¹⁷

Telephone and Electronic Communications with Patients

12. Physicians must capture in the medical record (e.g., document or upload, where relevant) details of all communication with patients related to clinical care that occur via telephone, or other digital means (e.g., e-mail,¹⁸ patient portals or other digital platforms), including the mode of communication.

Corrections to Medical Records

13. Where it is necessary to correct an inaccurate or incomplete medical record physicians must:
    1. date and initial the additions or changes and either:
       1. maintain the incorrect information in the record, clearly label it as incorrect, and ensure the information remains legible (e.g., by striking through incorrect information with a single line); or
       2. remove and store the incorrect information separately and ensure there is a notation in the record that allows for the incorrect information to be traced;^{19, 20} and
    2. consider whether to notify any health care providers involved in the patient’s care, considering factors such as whether the correction would have an impact on treatment decisions.
14. In accordance with the Personal Health Information Protection Act, 2004, physicians who make a correction in response to a patient request must: 
    1. inform the patient of the correction made, and
    2. at the request of the patient, inform in writing those who have received the incorrect information, if:
       1. it is reasonably possible to do so, and
       2. the correction is reasonably expected to have an effect on the ongoing provision of health care or provide other benefits to the patient.²¹
15. If the physician is of the opinion that a requested correction is unwarranted (i.e., patient has not demonstrated to their satisfaction that the record is incomplete or inaccurate), the physician must:
    1. give the reasons for the refusal, and
    2. inform the patient that they are entitled to:
       1. prepare a statement of disagreement that sets out the correction;
       2. attach the statement of disagreement to the medical record and disclose the statement of disagreement whenever information related to the statement is disclosed;
       3. require the physician to make reasonable efforts to disclose the statement to anyone who the physician would have notified had the physician made the correction (see provision 14 above); and
       4. make a complaint to the Information and Privacy Commissioner of Ontario.²²

Endnotes

^1. Personal Health Information Protection Act, 2004, S.O. 2004, c.3, Sched. A (hereinafter PHIPA); Part V of the General, Ontario Regulation 114/94, enacted under the Medicine Act, 1991, S.O. 1991, c. 30 (hereinafter Medicine Act, General Regulation); General, Ontario Regulation 57/92, enacted under the Independent Health Facilities Act, R.S.O.1990, c.1.3 (hereinafter IHFA, General Regulation); Hospital Management, Regulation 965 enacted under the Public Hospitals Act, R.S.O. 1990, c.P.40 (hereinafter Public Hospitals Act, Hospital Management Regulation); Health Insurance Act, R.S.O.1990, c. H.6 (hereinafter Health Insurance Act).

^2. Additional expectations for record-keeping are set out in other College policies, including Medical Records Management, Transitions in Care, Closing a Medical Practice, Protecting Personal Health Information, Managing Tests, Consent to Treatment, and Prescribing Drugs.

^3. Medicine Act, General Regulation, s. 18(3).

^4. There are circumstances where a physician’s records are transcribed on the physician’s behalf. In these circumstances the notation “dictated but not read” is often used to signify that that the physician has not yet reviewed the transcription for accuracy. The Canadian Medical Protective Association’s article "Dictated but not read": Unreviewed clinical record entries may pose risks sets out advice on how to mitigate risks when dictating medical record entries or reports.

^5. Section 18(3)(b) of Medicine Act, General Regulation requires records to be kept in a systematic manner.

^6. Additional guidance related to appropriate documentation is set out in the Advice to the Profession: Medical Records Documentation document.

^7. Section 17.4 (5) of the Health Insurance Act requires records to be prepared promptly when the service is provided. Additional guidance on best practices for documentation completion is set out in the Advice to the Profession: Medical Records Documentation document.

^8. Some components of the medical record have specific requirements for completion. Please see the College’s Transitions in Care policy for expectations related to completing and distributing discharge summaries and consultation reports.

^9. For additional guidance related to templates please refer to the Advice to the Profession: Medical Records Documentation document.

^10. 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.

^11. Documenting the date of the professional encounter is a requirement under s.18 of the Medicine Act, General Regulation; s. 19(2) of the Public Hospitals Act, Hospital Management Regulation requires each entry in a medical record to indicate the date on which it was made.

^12. A sustained physician-patient relationship is physician-patient relationship where care is actively managed over multiple encounters.

^13. There may be variations in content and format of the CPP or equivalent patient health summary based on the physician’s practice area and the nature of the physician-patient relationship (i.e., whether there is a sustained physician-patient relationship).

^14. For a consultation, s.18 (1) of the Medicine Act, General Regulation requires medical records to contain indication of the name and address of the primary care physician and of any health professional who referred the patient.

^15. For additional guidance regarding information that must be contained in a referral note and consultation report, please refer to the College’s Transitions in Care policy.

^16. Guidance for documenting operative and procedural notes is set out in the Advice to the Profession: Medical Records Documentation document.

^17. Sections 19(4) and 19(5) of the Public Hospitals Act, Hospital Management Regulation set out a number of additional requirements for documentation in a hospital setting. Physicians who practise in hospitals are advised to refer to the regulation for information about the specific requirements.

^18. For expectations related to e-mail communications with patients please refer to the College’s Protecting Personal Health Information policy. 

^19. These requirements are reflective of PHIPA, s. 55(10).

^20. With an electronic record, this can be achieved by using a digital strikeout (e.g., “track changes”) or where this is not possible, an addendum explaining the necessary changes.

^21. PHIPA, s. 55 (10).

^22. PHIPA, s. 55(11). For additional requirements pertaining to corrections, please refer to s. 55 of PHIPA.