The Patient Medical Record
For records of physicians in private practice, the following are required:
- A member shall make records for each patient containing the following information:
- The name, address, and date of birth of the patient;
- For a consultation, the name and address of the primary care physician and of any health professional who referred the patient;
- Every report received respecting the patient from another member or health professional;
- The date of each professional encounter with the patient;
- A record of the assessment of the patient, including,
- the chief complaint or reason for the assessment;
- the history obtained by the member;
- the particulars of each medical examination by the member; and
- a note of any investigations ordered by the member and the results of the investigations.
A record of the diagnosis or provisional diagnosis;
A record of the disposition of the patient, including,
- an indication of each treatment prescribed or administered by the member;
- a record of professional advice given by the member; and
- particulars of any referral made by the member.
Where appropriate, a cumulative patient profile or consolidated problem list is recommended;
- A record of all fees charged which were not in respect of insured services may be kept separately from the clinical record.
- A member shall keep a continuous record containing the name of each patient who is encountered professionally or treated or for whom a professional service is rendered by the member.
- The records required by regulation shall be:
- legibly written or typewritten or, if in an electronic data base, available to be produced in hard copy;
- kept in a systematic manner; and
- kept in a manner which maintains security from unauthorized access.