Duties and responsibilities

Expectations of physicians in practice

Medical records

Using electronic record systems with care
EHR and EMR technologies change the way medical care is delivered, creating both opportunities and challenges for healthcare providers.
Responding to a billing audit: How good records can help
Adequate record keeping may help during a billing audit.
Did you know? Patients can restrict access to their health information
Physicians should try to accommodate patients’ requests to limit access to their personal health information.
Providing medical records to patients seeking alternative medicine
Physicians should speak with patients about their alternative medicine treatments and, as much as possible, provide guidance on potential negative interactions.
"Dictated but not read": Unreviewed clinical record entries may pose risks
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.
Improving patient handovers
Patient handovers can be a time of high risk. Patient safety experts recommend various strategies to improve the performance of this task.
Managing access to electronic health records
A discussion of the principles of access, the challenges with access, and managing the risks.
Sharing records, improving care, staying safe
Providing patients with online access to their electronic medical records may offer improvements in patient health. Physicians should keep in mind their obligations to protect patient information and document appropriately.
Protecting patient health information in electronic records
Tips for using electronic records and other technologies.
Common medico-legal questions asked by members
A sample of medico-legal questions posed by CMPA members to physician and legal experts at the Association's education programs.
A matter of records: Retention and transfer of clinical records
An overview of the principles of retention, sharing and transferring of medical records.
Encryption just makes sense
Privacy legislation, regulatory policies and professional obligation require that CMPA members take reasonable measures to protect the privacy of their patients' personal health information. With the advent of electronic records, members should be cognizant that encryption can help secure personal health information and may be required by law.
Releasing a patient’s personal health information: What are the obligations of the physician?
To respond appropriately to a request to release patient information, physicians must understand the legal rules surrounding the ownership and handling of the information.
Managing the medico-legal risks of placing a central line
Litigation related to the placement of central lines is most often related to consent, delegation, standard of care, and documentation.
Why good documentation matters
Poor charting may be perceived as reflecting less attention to detail and risks the conclusion the care provided was poor.
A good defence depends on good records
CMPA provides free telephone record pads for physicians to use when documenting telephone advice.
Responding to requests for children's medical records
The physician's role in providing a child's medical information to a parent.
Anatomy of a well-written note
Avoid medico-legal difficulties by writing factual and objective notes.
Medical records: Advice about maintaining their integrity and providing them to lawyers
CMPA answers your questions about documentation.
Considerations when leaving a medical practice
Notifying and transferring patients and medical records when making a practice transition.
Physicians and their patients' wills: issues to consider
Physicians may be asked to attest to the capacity of a patient if the patient's will is contested or at the time the will is being prepared.
Ill-considered statements can be costly
Statements in medical records should be accurate, objective and factual.
Provincial counsel commentary: The Krever Inquiry
An inquiry into the Canadian blood system recommended improved documentation and informed consent, and decreased allogeneic blood use.

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.