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.
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.
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.
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.