Dialogue Volume 15, Issue 3 2019 | Page 33

POLICY MATTERS 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 electronic records: • 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- able. • 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 assessments). • 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 MD ISSUE 3, 2019 DIALOGUE 33