Comply with all Legal Requirements

The medical record is a legal document which records
events and decisions that help physicians manage patient
care. A physician following the recommendations in this
policy will be in compliance with the record keeping
requirements of the College and requirements set out in
the Ontario Regulations made under the Medicine Act
(referred to in this policy as the “regulation”).2 The regulation
is included at Appendix A.
Many physicians are also associated with institutions
or facilities that may have their own record keeping
requirements. Physicians to whom this applies should
investigate and be familiar with those legal obligations
that may arise in the Public Hospitals Act, the Long-
Term Care Act, or the Independent Health Facilities Act.
Other legislation, such as the Mental Health Act and
the Personal Health Information Protection Act
(PHIPA)3 also has an impact on medical records,
either on what is in them or to whom they may be
transferred. These will be referred to in more detail in
the applicable sections below.