Do Physicians Have to Do Document the Date That a Medical History Form Is Reviewed?

Medical Records Documentation

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

Policies of the College of Physicians and Surgeons of Ontario (the "Higher") set out expectations for the professional conduct of physicians practising in Ontario. Together with the Exercise Guide and relevant legislation and case law, they will be used past the College and its Committees when considering physician exercise or deport.

Inside policies, the terms 'must' and 'advised' are used to articulate the College'southward expectations. When 'brash' is used, it indicates that physicians tin use reasonable discretion when applying this expectation to practice.

Additional information, general advice, and/or best practices tin be found in companion resources, such every bit Communication to the Profession documents.

Definitions

Cumulative Patient Contour (CPP) or equivalent patient wellness summary : A summary of essential information nigh a patient that includes critical elements of the patient'due south 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 intendance journey. As such, physicians' documentation in the medical record must be:
   1. legible;³
   2. understandable to health care professionals reading the tape, including avoiding the utilize of abbreviations that are known to have more than than 1 significant 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'south health status and concerns;
      3. any pertinent details that may exist useful to the md or hereafter wellness 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 handling or procedure is axiomatic in the tape);
   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 tape is professional and not-discriminatory, and in accordance with the Higher's Professional Obligations and Human being Rights policy.⁶

Timing of Documentation

4. To support the prophylactic delivery of intendance, physicians must document their patient encounters as soon as possible.^{seven, 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 accurateness and completeness prepare 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 (due east.g., templates that let 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 run across and that all pertinent details well-nigh the patient'due south wellness status accept 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 engagement each entry in the medical record. Where the date of the patient see differs from the date of documentation, physicians must record both dates.^eleven

CPP or Equivalent Patient Health Summary

8. Primary care physicians must include an easily accessible, accurate, and upwardly to engagement CPP, or an equivalent patient health summary, in each patient medical record, which includes the following, where applicative:
   1. patient identification;
   2. patient contact information;
   3. personal and family data (eastward.thousand., occupation, life events, habits, family unit medical history);
   4. by medical history (due east.chiliad., by serious illnesses, operations, accidents, genetic history);
   5. risk factors;
   6. allergies and drug reactions;
   7. ongoing health weather condition (e.k., problems, diagnoses, date of onset);
   8. health maintenance (due east.yard., periodic health exams, immunizations, disease surveillance);
   9. names of any consultants involved in the patient's intendance;
   10. long-term management needs (e.1000., current medication, dosage, frequency);
   11. major investigations;
   12. appointment the CPP was concluding updated; and
   13. contact person in case of emergencies.
9. All other physicians must use their professional person judgement to make up one's mind whether to include a CPP or an equivalent patient health summary in each patient medical record, because a diverseness of factors, such equally the nature of the physician-patient relationship (e.one thousand., 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 post-obit for all patient encounters, where indicated:
    1. presenting complaint;
    2. a focused relevant history;
    3. an cess and an advisable focused test;
    4. a diagnosis and/or differential diagnosis;
    5. any treatment or therapy provided and the patient's response and outcomes; and
    6. a direction and follow-up plan, including advice given to patients and/or intendance givers.
11. Physicians must capture details of the following in each patient medical record:
    1. any prescriptions issued in accordance with the Higher'due south Prescribing Drugs policy;
    2. consent in accordance with the College's Consent to Treatment policy and any consent to handling obtained in writing;
    3. all tests requisitioned and referrals made¹⁴, including a copy of the referral note, and any associated reports and results (due east.g., laboratory, diagnostic, pathology);^fifteen
    4. any treatments, investigations, or referrals that have been declined or deferred, the reason, if whatsoever, given by the patient, and word of the risks;
    5. any operative and procedural records;^sixteen and
    6. any belch 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 phone, or other digital means (e.k., e-mail service,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, conspicuously label it as incorrect, and ensure the information remains legible (eastward.g., past hitting through incorrect information with a single line); or
       2. remove and store the incorrect data separately and ensure at that place is a notation in the record that allows for the incorrect information to be traced;^{19, 20} and
    2. consider whether to notify whatsoever wellness care providers involved in the patient's intendance, considering factors such as whether the correction would have an impact on treatment decisions.
14. In accordance with the Personal Health Data Protection Act, 2004, physicians who make a correction in response to a patient request must:
    1. inform the patient of the correction fabricated, 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 exercise then, 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.east., patient has not demonstrated to their satisfaction that the record is incomplete or inaccurate), the doc must:
    1. give the reasons for the refusal, and
    2. inform the patient that they are entitled to:
       1. fix a statement of disagreement that sets out the correction;
       2. adhere the argument of disagreement to the medical tape and disembalm the statement of disagreement whenever information related to the statement is disclosed;
       3. require the physician to brand reasonable efforts to disclose the statement to anyone who the physician would have notified had the dr. made the correction (meet provision fourteen above); and
       4. make a complaint to the Information and Privacy Commissioner of Ontario.²²

Endnotes

^ane. Personal Health Data 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. thirty (hereinafter Medicine Human action, General Regulation); Full 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.twoscore (hereinafter Public Hospitals Act, Infirmary Management Regulation); Health Insurance Act, R.S.O.1990, c. H.half dozen (hereinafter Health Insurance Act).

^ii. Additional expectations for record-keeping are gear up out in other College policies, including Medical Records Management, Transitions in Care, Closing a Medical Exercise, Protecting Personal Wellness Data, Managing Tests, Consent to Handling, and Prescribing Drugs.

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

^four. At that place are circumstances where a physician'south records are transcribed on the physician's behalf. In these circumstances the note "dictated but not read" is often used to signify that that the physician has non notwithstanding 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, Full general Regulation requires records to be kept in a systematic manner.

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

^7. Section 17.iv (5) of the Health Insurance Human activity requires records to exist 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 certificate.

^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 belch summaries and consultation reports.

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

^10. Section 18(1) paragraphs 1 and 2 of the Medicine Deed, 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.

^xi. Documenting the date of the professional see is a requirement under s.18 of the Medicine Human activity, General Regulation; s. 19(ii) of the Public Hospitals Act, Hospital Management Regulation requires each entry in a medical record to indicate the date on which it was fabricated.

^12. A sustained physician-patient human relationship is physician-patient relationship where intendance 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 expanse and the nature of the physician-patient relationship (i.east., whether at that place is a sustained doctor-patient relationship).

^xiv. For a consultation, s.eighteen (ane) of the Medicine Act, Full general Regulation requires medical records to contain indication of the name and address of the primary intendance physician and of any health professional who referred the patient.

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

^xvi. 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 Direction Regulation set up 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 near the specific requirements.

^18. For expectations related to due east-mail service communications with patients delight refer to the College's Protecting Personal Wellness Information policy.

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

^20. With an electronic record, this can be achieved by using a digital strikeout (due east.yard., "track changes") or where this is non possible, an annex explaining the necessary changes.

^21. PHIPA, southward. 55 (10).

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

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Source: https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Medical-Records-Documentation

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