PRINCIPLES of Medical Records

Good medical record keeping is part of providing the
best quality of medical care.
Physicians are obligated to make records for each of
their patients. The primary use of these records is for
the treating physician and other health care professionals
to ascertain the patient’s medical history and identify
problems or patterns that may help determine the
course of health care that should follow. In addition,
good records can help optimize the use of resources,
both financial and human, by reducing duplication of
services and, sometimes, by identifying abuse of the
health care system. They may also provide information
essential to others for a wide variety of purposes:
billing; research; and response to public complaints,
legal proceedings or insurance claims, for example.
Some of the elements of the guidance provided below
are mandatory: either required by law, or expected by
the College as a minimum practice standard. Wherever
this is the case, the policy will explicitly indicate that
adherence is obligatory. In some cases, the obligations
do not arise from medical practice standards but from
Ontario Health Insurance Plan (OHIP) requirements:1
such instances are identified in the text. Other components
of the policy are offered as recommendations as
to the best means of providing patients with quality
medical care. These references have been included to
provide physicians with as much information about
record keeping as possible, but are not College requirements
for medical record keeping. The ultimate objective
of the policy is to set out what must be kept in
medical records and to provide physicians with a tool
that will permit them to maintain a record keeping system
that is functional, practical and easy to maintain.