Timing of the Events

All patient-related documentation must be dated.
Consultation reports, laboratory and diagnostic results
must be manually or electronically initialed and dated
when they are reviewed. Every patient encounter must
be documented and dated in the medical record.
Where there will be more than one physician making
entries in a record, each physician’s entry must be identified
by signature and, if appropriate, position or title.
The Health Insurance Act (relevant excerpts of which
can be found at Appendix C) requires that physicians
record the start and stop time for certain types of
patient encounters, such as psychotherapy and counselling.
In addition to these, it is prudent for physicians
to record the start and stop times for some other
types of clinical encounters, such as procedures in the
ER, resuscitation, administration of medications, and
telephone conversations.
The College recommends that entries be recorded as
closely as possible to the time of the encounter, when
the detail is most fresh in the physician’s mind. This
will allow physicians to keep records that are detailed,
accurate and comprehensive