The practice of marking transcribed reports or entries “dictated but not read” gives rise to medical-legal risks and can create uncertainty for those relying on that information in providing patient care.
Actions physicians can take to mitigate potential risks of using patient portals to communicate clinical information with patents.
Physicians may face a privacy breach when viewing personal health information that is not required for current clinical care and without the patient’s or information custodian’s consent.
Documentation in clinical notes and reports to third parties should be factual, objective, and use a suitable tone of medical professionalism.
Practising physicians, particularly those at the beginning of their career, should ensure they have enduring access to medical records after leaving a practice for medical-legal purposes.
A review of CMPA member enquiries following the legalization of cannabis for recreational use reveals that the new regulatory regime has generally not had a significant medical-legal impact for our members.
An overview of the principles of retention, sharing and transferring of medical records.
An overview of information privacy considerations when using electronic medical records in practice.
CMPA gives advice to physicians travelling across international borders and having border agents search mobile electronic devices, such as smartphones, that may contain confidential patient information.
Strategies for managing the stress associated with transitioning to a new EMR system for managing patient records.
Addressing privacy breaches has become more complex as the rules around notifying and reporting have recently changed or are about to change across the country.
Physicians can be better prepared to transfer patient health information when they understand who has custody of and access to medical records.
Individuals have a general right to access their personal information in independent medical examination files, but there are exceptions to what must be produced
Physicians may release a patient’s medical records to lawyers only with patient authorization or where required by law.
Physicians working with medical scribes should be aware of their obligations as an employer, delegator, and supervisor.
Physicians should try to accommodate patients’ requests to limit access to their personal health information.
A discussion of the principles of access, the challenges with access, and managing the risks.
To respond appropriately to a request to release patient information, physicians must understand the legal rules surrounding the ownership and handling of the information.
Responsibilities of physicians when planning to close or leave a practice due to retirement, illness, or other reasons.
The physician's role in providing a child's medical information to a parent.