Duties and responsibilities

Expectations of physicians in practice

Medical records

Why do you need to know? A balancing act for accessing personal health information
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.
Writing with care
Documentation in clinical notes and reports to third parties should be factual, objective, and use a suitable tone of medical professionalism.
My patients, my records?
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.
Cannabis legalization in Canada, one year later: Questions from members
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.
How to manage your medical records: Retention, access, security, storage, disposal, and transfer
An overview of the principles of retention, sharing and transferring of medical records.
Protecting patient health information in electronic records
An overview of information privacy considerations when using electronic medical records in practice.
Can border agents search your smartphone?
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.
Managing stress when transitioning to new electronic record systems
Strategies for managing the stress associated with transitioning to a new EMR system for managing patient records.
The new reality of reporting a privacy breach
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.
Who has custody of medical records, and who can they be shared with?
Physicians can be better prepared to transfer patient health information when they understand who has custody of and access to medical records.
Providing access to independent medical examinations
Individuals have a general right to access their personal information in independent medical examination files, but there are exceptions to what must be produced
Did you know? You need authorization to provide medical records to lawyers
Physicians may release a patient’s medical records to lawyers only with patient authorization or where required by law.
Medical scribes: An increasing reality
Physicians working with medical scribes should be aware of their obligations as an employer, delegator, and supervisor.
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.
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.
Closing or leaving a practice: Tips for primary care physicians
Responsibilities of physicians when planning to close or leave a practice due to retirement, illness, or other reasons.
Responding to requests for children's medical records
The physician's role in providing a child's medical information to a parent.
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.

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.