Removing Portions of the Record

Sometimes storage requirements may necessitate the
removal of some materials from a patient’s active
chart. If investigation results and consultation reports
are no longer relevant to the patient’s current care, it is
permissible to store them elsewhere (in accordance
with the retention requirements set out in the regulation,
see below for further detail). In such instances,
the physician should make a notation indicating that
documents have been removed from the chart and the
location where they have been stored.

Clarity and Legibility
The regulation requires that medical records be legible.
5 Furthermore, the College expects that the records
can be interpreted by the average health care professional.
If there is difficulty with the legibility of the
records, an alternate means of note taking should be
considered (e.g., voice dictation, electronic medical
records, or handwriting recognition software).
Using conventional medical short forms is permissible.
However, the meaning should be readily available to
a health care professional reading the record.