Laws regarding promptly updating medical records
In settings such as walk-in clinics, single patient files must be created and all documentation for a single patient must be kept in that patient’s file. Physicians must always obtain the patient’s consent when collecting, using or disclosing personal health information (PHI), unless provided otherwise by law.If the collection, use, or disclosure is neither permitted nor required by law and therefore patient consent must be obtained, physicians should note that as members of what is commonly referred to as the “circle of care,” Physicians may wish to engage commercial providers for services such as storage, maintenance, scanning, destruction, and other issues related to medical records.These agreements must reflect the same legal and regulatory requirements that apply to physicians as health information custodians.Physicians are encouraged to seek legal counsel or contact the CMPA for advice in these circumstances.Physicians are ultimately responsible for ensuring that medical records are stored and maintained according to legal requirements and the principles set out in this policy.Medical records must be stored in a safe and secure environment to ensure physical and logical integrity and confidentiality.This policy establishes principles and requirements for all medical records and applies to all physicians.
In accordance with The Practice Guide, the professional expectations in this policy are based on the following principles: The College expects all physicians to keep medical records that are consistent with their legal obligations and the expectations set out in this policy.Physicians must develop records management protocols to regulate who may gain access to records and what they may do according to their role, responsibilities, and the authority they have.At minimum, protocols must ensure that patient records, in electronic or paper form, are readily available and producible when legitimate use is required, and that reasonable steps have been taken to ensure they are protected from theft, loss and unauthorized use or disclosure, including copying, modification or disposal.The physician must ensure the accuracy of the entries made into the medical record on his or her behalf by a trainee or the recipient of delegation. The In addition to these, physicians should ensure that the start and stop times are recorded for some other types of clinical encounters, such as resuscitation, administration of medications, and telephone conversations.The College recommends that entries be recorded as soon as possible after the encounter.