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I ]would strongly recommend that, under Sxn 5. – General Principles for Contents of Medical Records, Objective Data be rewritten to include Mental Status Examination appropriate to the presenting complaint. (Most studies show that up to 40% of patient visits may have a psychiatric component.)
The expectations of the office family physician’s are well-described. However, ER and walk-in clinic physician record-keeping is often cursory, poor, illegible and incomplete. This often results in substandard decision-making. Respecting the fact that ER physicians are often very busy, hurried and harried, I feel that the expected content of the ER and walk-in clinic record requires re-vamping and modernizing. Specifically, the ER record for major trauma, life-threatening scenarios and procedures requring conscious sedation need to be much more detailed and standardized (eg., documentation of primary and secondary surveys). These are detailed in trauma centre records, but poorly documented in community ER’s.
patients are increasingly asking for email interactions.
How is this viewed by the college since the security of email is not assured.
What can and cannot be discussed?
Keeping records on minors for ten years beyond the age of 18 is quite a burden.Perhaps it could be modified so that only the charts of those with major problems or those who might have life long problems found in their early years need be kept.As it is now,some records must be kept for 28 years ! Somewhat unnecessary for a baby seen with a pimple or diaper rash.
RE Medical records policies –
I think any new guidelines should remove the burden from me of being an IT expert around security issues. As I understand it currently, if my EMR has flaws that are hackable, it is still ultimately my fault if my patients’ records get breached. I think most physicians do not have the personal knowledge to ascertain cybersecurity at this level, and just have to take the vendors word for it that their systems are robust enough. I really have no way to assess this reasonably, except if their is evidence of previous system failure . I think this is important to take into account increasingly as technology changes, and more and more information is transmitted and stored “ in the cloud”.
Thanks for considering.
This is an excellent comprehensive document and reiterates information with which many physicians are familiar. There are many other personnel who have appropriate access to medical records, and their level of knowledge of requirements are not always at a suitable level. While this document is readily available, those who are not members of CPSO may not easily access this document without it being provided by a physician. I strongly endorse providing this for professional Nursing associations, for instance, as well as those who are professional keepers of medical records (such as in provincially or federally run institutions, for an example), and perhaps even for clerks and support staff. I would also suggest a quick check-list to distribute to those who might be, or should be, interested in knowing their responsibilities in securing the information within medical records. There is much misinformation about who should and should not, have ready access, and what exactly constitutes safe record keeping.
I am comfortable with this policy. I don’t know if there is anywhere to add how time consuming medical documentation is and at times becomes onerous… I am quite vigilinat about documentation in our EMR but the non-stop daily pressure to keep up with everything is difficult.
Thank you for allowing me to review this policy.
not sure if this will get any traction but I did email cpso re suggestion for guidelines around referring and consulting physicians
I did not get a response so thought I might try here
not directly related but has some bearing
pls look at the guidelines that exist in nova scotia at https://www.cdha.nshealth.ca/system/files/sites/833/documents/cpsns-guidelines-referral-amp-consultation-summer-2010.pdf
we need something in Ontario to provide similar guidance
A clear and comprehensive policy for family physicians. I’ve reviewed this policy a few times while transitioning from paper to two different EMR’s. CPSO cannot expect physicians to guarantee safety/EMR compliance with CPSO policy if/when the physician has no control over certain aspects of the EMR. For example, the current EMR I use (OntMD certified) went bankrupt soon after it went live and users identified multiple safety issues (such as flow sheets being populated with lab values inaccurately: we resorted to paper.) Widely used standardized tools (eg Rourke/opioid manager) are not available or if available, cannot be updated to reflect latest evidence. We will soon transition to a different EMR (the third in 6 years!) with all the data migration/time/effort/expense that entails. I look forward to the day when the EMR wars are over and digital health care is connected and meets all the stakeholder policies. Time spent on data entry/software troubleshooting/contacting technical support/mitigating software problems/filling out incident reports is time not spent doing the work for which I am trained, educated, (and highly prefer.)