MEDICAL RECORDS DOCUMENTATION
Fees for Records
Consistent with the College’s Uninsured Services:
Billing and Block Fees policy, the draft policy requires
physicians to consider the patient’s ability to pay, when
determining a reasonable fee.
Electronic Medical Records
The draft policy proposes some new expectations for
• Physicians are prohibited from sharing their credentials
or passwords. This is consistent with the legal require-
ment for an audit trail and that all entries are identifi-
• Physicians are required to only use certified EMRs, un-
less they can independently verify that an unaccredited
EMR meets privacy and security standards.
• Physicians are required to be proficient with their
electronic record-keeping system in order to meet
legislative and regulatory requirements and participate
in regulatory processes (e.g., College investigations and
• The maintenance of dual record-keeping systems (i.e.,
both paper and electronic records) was identified in
the feedback and research as being problematic. In
response, the draft policy requires setting an official date
for the use of the new (electronic) system (i.e., a “go live
date”) and only documenting in that system from the
official date onward.
How to Document
• In an era of greater transparency (e.g., patient portals)
and consistent with other regulators, the draft policy
now requires documentation to be professional and
non-judgmental, in accordance with the Professional
Obligations and Human Rights policy.
• Physicians’ documentation must be unique to each
patient encounter, i.e. refrain from inappropriate use of
cut and paste
What to Document
• The draft policy retains the requirement for primary
care physicians to maintain a Cumulative Patient Profile
(CPP) and now requires all other physicians to use their
professional judgment to determine whether to include
a CPP or equivalent patient health summary.
• Physicians are required to record both the date of the
patient encounter and the date of documentation,
where the dates differ.
• Physicians are required to use their professional judg-
ment to determine whether to document discussions
with others involved in the patient’s care (e.g., tele-
phone, email), giving consideration to factors such as
whether the discussion informed treatment decisions
ISSUE 3, 2019 DIALOGUE