Duties and responsibilities

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.

EHR and EMR technologies change the way medical care is delivered, creating both opportunities and challenges for healthcare providers.

Adequate record keeping may help during a billing audit.

Physicians should try to accommodate patients’ requests to limit access to their personal health information.

Physicians should speak with patients about their alternative medicine treatments and, as much as possible, provide guidance on potential negative interactions.

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.

Patient handovers can be a time of high risk. Patient safety experts recommend various strategies to improve the performance of this task.

A discussion of the principles of access, the challenges with access, and managing the risks.

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.

To respond appropriately to a request to release patient information, physicians must understand the legal rules surrounding the ownership and handling of the information.

Litigation related to the placement of central lines is most often related to consent, delegation, standard of care, and documentation.

Responsibilities of physicians when planning to close or leave a practice due to retirement, illness, or other reasons.

CMPA provides free telephone record pads for physicians to use when documenting telephone advice.

The physician's role in providing a child's medical information to a parent.

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.