Medical Records – Preliminary Consultation (CLOSED)

The College’s Medical Records policy is currently being reviewed. The policy sets out physicians’ legal and professional obligations with regard to medical records. The policy explains how medical records must be kept and outlines general requirements regarding the collection, use, security, storage, and disclosure of patients’ personal health information with respect to both paper and electronic records. In addition, the policy sets out requirements regarding retention, access and transfer of records, along with the specific information that must be included in records and how it must be documented. The policy contains specific requirements in regard to records for procedural medicine.

View the current policy

To assist with this review, we are inviting feedback from all stakeholders, including members of the medical profession, the public, health system organizations and other health professionals on the current policy. Comments received during this preliminary consultation will assist the College in updating the policy. When a revised draft is developed, it will be recirculated for further comment before it is finalized by Council.

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We want to hear your thoughts on the current policy…

• Submit your comments to our discussion forum
• Complete a brief online survey concerning the current policy
• Send us your comments via Email

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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. It is a living document that tells the story of the patient and facilitates each encounter he/she has with health professionals involved in their care. In addition to telling the patient’s story, complete and accurate medical records will meet all legal, regulatory and auditing requirements. Most importantly, however, they will contribute to comprehensive and high quality care for patients by optimizing the use of resources, improving efficiency and coordination in team-based and interprofessional settings, and facilitating research.

The purpose of this policy review is to assess the current policy and determine what revisions may be required to ensure that the policy is clear, informative, and reflective of the medical record issues often encountered in medical practice.

Have Your Say

We would like to hear your thoughts on the current policy, along with suggestions you may have for how the policy could be improved.

In particular, we are interested to know:

• Does the policy clearly articulate the physician’s legal and professional obligations with respect to medical records?
• Are there any issues not included in the current policy that should be addressed? If so what are they?
• Are there other ways in which the policy could be improved?

The deadline to provide feedback on the current policy is December 4, 2017.

Next Steps

The College is committed to ensuring that the Medical Records policy embodies the values and duties of medical professionalism, and is consistent with the College’s mandate to protect the public. The feedback obtained during this consultation will be carefully reviewed and used to evaluate the draft. While it may not be possible to ensure that every comment or suggested edit will be incorporated into the revised policy, all comments will be carefully considered.

Once a revised draft policy has been developed, stakeholders will be invited to review the revised document and provide further feedback before it is considered for final approval by Council.

Final decisions regarding policy revisions are made by College Council.

To ensure transparency, the College will post all consultation feedback in accordance with our posting guidelines.

We value your feedback and thank you again for participating in our policy review process.

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