Regulation #12

The Patient Medical Record

For records of physicians in private practice, the following are required:

  1. A member shall make records for each patient containing the following information:

    1. The name, address, and date of birth of the patient;
    2. For a consultation, the name and address of the primary care physician and of any health professional who referred the patient;
    3. Every report received respecting the patient from another member or health professional;
    4. The date of each professional encounter with the patient;
    5. A record of the assessment of the patient, including,

      1. the chief complaint or reason for the assessment;
      2. the history obtained by the member;
      3. the particulars of each medical examination by the member; and
      4. a note of any investigations ordered by the member and the results of the investigations.
    6. A record of the diagnosis or provisional diagnosis;

    7. A record of the disposition of the patient, including,

      1. an indication of each treatment prescribed or administered by the member;
      2. a record of professional advice given by the member; and
      3. particulars of any referral made by the member.
    8. Where appropriate, a cumulative patient profile or consolidated problem list is recommended;

    9. A record of all fees charged which were not in respect of insured services may be kept separately from the clinical record.

  2. 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.

  3. The records required by regulation shall be:

    1. legibly written or typewritten or, if in an electronic data base, available to be produced in hard copy;
    2. kept in a systematic manner; and
    3. kept in a manner which maintains security from unauthorized access.

    Adopted 4/96