Electronic Records

All of the principles discussed in this policy apply
equally to electronic records. The records must contain
the story of the patient. While there is some
debate about the preferred format of electronic
records (e.g., template-based records vs. voice dictation-
based records), an electronic format will be adequate
if it can capture all the pertinent personal health
information and allows the user to centralize the
essentials of the patient’s story on several screens. If
the format cannot do this, it is probably not satisfactory
and the physician should consider using an alternative
system.
The College recognizes some limitations of electronic
records at the time of writing this policy. In many
cases, the printable version of the electronic record
does not readily enable a reviewer to understand the
whole patient record and is, therefore, of limited use.
Furthermore, some of the systems do not readily allow
the physician to capture nuances of the patient
encounter. Physicians using such systems must ensure
that each record entry captures the unique aspects of
that particular patient encounter. The College is aware
that this is a developing area and that there is great
potential for electronic record keeping to enhance the
practice of medicine.
Physicians have an obligation to provide printed
copies of electronic records when asked to do so. In
order to ensure they can be understood, some physicians
provide the print-out from the electronic record
together with a dictated summary to provide an
overview of the patient’s story.
Specific requirements for physicians who maintain
electronic patient records are set out in sections 18-21
of Ontario Regulation 114/94, listed in Appendix A.
The College notes that residents frequently retain
patient information on PDAs and laptops in order to
track workload and for educational purposes. Issues
about storage, deletion of records and privacy of
health information can pose the same problems in this
context as discussed elsewhere in this policy, and those
who are using records in this fashion are cautioned to
ensure that they are doing so in adherence to the policy.