Advanced search

Documentation and medical records

This page is your starting point to CMPA's articles on documentation and medical records.

Purpose of medical records

The medical record serves to document information about a patient encounter. It is an important part of every physician's practice because it:

• provides a record of medical reasoning, and facilitates further investigations and treatments
• facilitates communication in collaborative health care teams
• medical regulatory authorities (Colleges) require written records as a standard of practice, and many provinces/territories require them in law
• serves as valuable evidence for the defence of a legal action or complaint

Good documentation

A good entry in a medical record is clear, complete, and legible; entered soon after the patient encounter (contemporaneous); summarizes the pertinent facts of the encounter; and lists differential diagnoses and a final diagnosis if known.

The article "Good notes vs. bad notes" provides tips for writing good medical record entries as well as practices to avoid, while "Ill-considered statements can be costly" illustrates why such entries should be objective and factual. "Cautionary tales: telephone advice" provides key points on medical advice given over the telephone or electronically.

The eLearning activity Documentation: Charting Medical Records describes the elements of a good medical record.

Changing information in a medical record

Medical records should not be tampered with after learning of a legal action or receiving a threat of legal action or complaint.

The article "The medical record: A legal document—can it be corrected?" includes suggestions about how and when to make corrections to medical record entries if needed, and "A case for keeping good notes" spotlights a College complaint case.

Retaining records

Provincial/territorial legislation and/or College policy define the period of time for which a physician must keep clinical records after the date of last entry in the record.

"A matter of records: retention and transfer of clinical records" lists the required retention periods in each province/territory.

Transferring records

When a physician leaves a practice or a patient finds a new attending physician, the existing medical record may need to be transferred elsewhere. Authorization from the patient prior to the transfer should be obtained, and the original record should be retained for the duration of the applicable retention period.

The article "Considerations when leaving a medical practice" describes how to transfer and store medical records, while "Medical records: Advice about maintaining their integrity and providing them to lawyers" answers common questions about providing information requested by lawyers.

Access to information

While the treating physician or health facility owns the physical record, patients own the information in their medical records and have the right to access this information. Privacy legislation in each province/territory defines an individual's right to control personal information. If a physician fails to comply with the legislation or a patient is dissatisfied, the physician could face a complaint.

The articles "Office privacy compliance – part 3", and "A matter of records: retention and transfer of clinical records" suggest how to respond to patient requests for information in their medical records.

When parents ask a physician to disclose information about their child, the question of whether the parent is entitled to the information arises. The article "Responding to requests for children's medical records" explains the different protocols that apply depending on whether the parents are "custodial parents," "access parents," or "parents with no right of access."

Electronic records

Many physicians and institutions are making the move from paper-based records to electronic records. As described in the article "Transitioning to electronic medical records," among the factors to consider when making the transition are what information should be migrated and how best to archive the existing record.

Information security

Electronic records pose new challenges for information security. Theft or loss of electronic devices containing patient information could breach privacy laws and patient confidentiality. Encryption and password protection can protect against such breaches.

Several articles help put this issue in perspective: "Encryption just makes sense" describes legislative encryption requirements, while "Protecting sensitive electronic health information – think encryption" illustrates the consequences of a potential privacy breach resulting from computer theft, and "Safeguarding your patients' privacy when data is stored on computers" includes privacy commissioner recommendations on appropriate protection and disposal of medical information.

Defence in medico-legal cases

Documentation plays a crucial role in the outcome of many medico-legal cases. Generally, the better the documentation the more likely the physician will be successful in defending the case. Examples include:

• incomplete documentation following a laryngospasm. ("Airway management issues in pediatric anesthesia")
• incomplete documentation in the case of a delay in diagnosis of acute coronary syndromes (ACS). ("Delay in diagnosis of ACS")
• good documentation that helped to defend a College complaint concerning a mother's request for a blood test for her daughter. ("A parent's demands: Making sound decisions when facing pressure from patients")
• poor documentation in which a paediatrician was found to fall below the standard of care in a case of missed diagnosis. ("Hyponatremia in children")
• inadequate documentation that led to inability to defend the case after the physician's death. ("Good notes can protect your family, too")

Learn more and earn CME credits

Complete the CMPA's eLearning activities on documentation / medical records and earn CME credits:

• Documentation, Charting Medical Records (Part 1): Describes the elements of good documentation.
• Documentation, Charting Medical Records (Part 2): Presents case studies in which documentation impacted the defence of physicians.