Electronic records handbook
Table of contents
Requirements for eRecord systems and physician obligations
All Canadian provinces and territories have express requirements regarding the creation and maintenance of medical records that must be followed. The specific requirements vary between jurisdictions.
Several Colleges have policies, bylaws, rules, or regulations concerning eRecords systems, which may include the following requirements. eRecords systems should generally:
- Visually display and print the recorded information for each patient promptly and in chronological order.
- Display and create a printed record in a format that is readily understandable to patients seeking access to their records.
- Provide access to the record of each patient using the patient’s name and medicare health number, if applicable.
- Maintain an audit trail that:
- records the date, time, and identity of the user when records are accessed.
- records the date and time of each information entry and the identity of the user making the entry.
- indicates any changes in the recorded information and the identity of the user making the change.
- preserves the original content of the recorded information when changed or updated.
- is capable of being printed separately from the recorded information for each patient.
- Have robust security features (including encryption, use of passwords, and access controls) to protect against unauthorized access.
- Automatically back up files and allow the recovery of backed-up files, and provide reasonable protection against information loss, damage, and inaccessibility.
Physicians should generally:
- Become familiar with medical regulatory authority (College) requirements, legislation, regulations, or other expectations regarding the use of eRecords in their province or territory.
- Review privacy legislation as, in some provinces and territories, it may contain specific provisions or expectations regarding eRecords.