Medical records: Advice about maintaining their integrity and providing them to lawyers
Of interest to all physicians
The CMPA receives many types of questions from members. Some are frequently asked; some are unexpected and require consultation with legal counsel. Most generate information that other members may find useful. Here, we share some of the learning from your questions.
The CMPA has been asked for advice about incorporating information from original laboratory records into a separate flow sheet that is then kept on the patient's chart as a quick overview of the patient's lab results. The question has been raised whether it is necessary to keep the original lab reports once the information is transferred to the flow sheets. The CMPA recommends that all original copies of lab results be maintained on the chart, even if the information is transferred to a secondary document. Indeed, some regulatory authorities (Colleges) explicitly require that the original report be retained.
About providing medical records to lawyers
Q: Should I send a patient's record when it is requested by a lawyer?
Q: Should I send the original or a photocopy?
Q: Does this request mean I'll be involved in a legal action?
Q: What should I copy?
Q: Can I charge the lawyer for photocopying?
If the lawyer subsequently requests more information, or if you later receive any legal document, members should contact the CMPA promptly for assistance.