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It is a living document that tells the story of the patient and facilitates each encounter they have with health professionals involved in their care.
Physicians are ultimately responsible for meeting the expectations set out in this policy and may assess their own medical record-keeping practices by answering the questions listed in Appendix C, which have been taken directly from a protocol used in the College’s peer assessment activities.
This policy establishes principles and requirements for all medical records and applies to all physicians.
The policy indicates any additional requirements that exist based on the type of record (e.g., paper, electronic or hospital-based records) or the physician’s practice (e.g., primary care, procedural medicine, group practice).
The purpose of this policy is to set out physicians’ professional and legal obligations with regard to medical records and to provide all practising physicians with a tool that will assist them in implementing record-keeping practices that are practical and easy to maintain.
Policy Number:#4-12 Policy Category: Administrative Under Review: No Approved by Council: November 2000 Reviewed and Updated: September 2005, November 2006, May 2012 College Contact: Physician Advisory Service Downloadable Version(s): Medical Records The medical record is a powerful tool that allows the treating physician to track the patient’s medical history and identify problems or patterns that may help determine the course of health care.
The primary purpose of the medical record is to enable physicians to provide quality health care to their patients.