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.
   
   

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