Medical Records – General Consultation

The College’s Medical Records policy is currently being reviewed. Two new draft policies, Medical Records Stewardship and Medical Records Documentation, have been developed and update the expectations of physicians regarding the care, handling, and management of medical records, as well as the expectations of physicians when documenting in medical records.

Two draft Advice to the Profession documents have also been developed as companion documents, providing general guidance and contextual information to help physicians interpret and apply the College’s expectations as set out in the draft policies.

Draft Policy • Advice Document	Draft Policy • Advice Document

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Key Features of the Draft Policies

The draft policies generally maintain the principles and expectations of the current policy, but the drafts have been reorganized and expectations have been divided into two separate policies to enhance their usability:

• Medical Records Stewardship updates and refines expectations related to the care, handling, and management of medical records (e.g., access and transfer, security and storage, and retention and destruction).
• Medical Records Documentation sets out how and what to document in patient medical records, and contains foundational principles that apply broadly across specialties and practice types (e.g., legibility, accuracy, comprehensiveness and timeliness).

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Have your say

We want to hear your thoughts on the draft policy. For example, we are interested to know:

• Do the draft policies and/or the advice document provide useful guidance?
• Are there issues not addressed in the draft policies and/or advice documents that should be addressed?
• How else could the draft policies and/or advice documents be improved?

Please submit your comments by November 22, 2019.

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Next Steps

Comments received during the consultation will be carefully reviewed and used to evaluate the draft policies and advice to the profession documents. Final decisions regarding policy revisions are made by College Council. A copy of the final policies and advice documents will be posted on this page as well as the College’s website.

We value your feedback and thank you for participating in this policy review.