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A medical record is an essential tool in providing continuity
of care for all patients, regardless of the nature
of the relationship between the physician and patient,
and/or the frequency of patient encounters. As stated
above, the record must tell the story of the patient’s
health care condition and should allow other health
care providers to quickly read and understand the
patient’s health concerns or problems.
Each record of a patient encounter, whether in a clinic
or at the patient’s home, must include a focused relevant
history, appropriate focused physical exam (when
indicated), a provisional diagnosis (where indicated)
and a treatment plan.

Communicating with Patients
The first step in taking a patient’s medical history is to
clarify and verify the patient’s reason for the visit. The
physician should be mindful that nonverbal communication
such as tone of voice, mannerisms and ‘body
language’ may give important clues as to the patient’s
underlying problem and concerns.
The College would expect a physician not to make
derogatory or inappropriate comments about a patient
in the record.

Collection of Information Indirectly
Physicians should, unless PHIPA provides otherwise,
always obtain the patient’s consent when collecting,
using or disclosing personal health information.
Physicians are permitted to collect information indirectly
without consent in the instances set out in section 36
of PHIPA. One example is where the information is
reasonably necessary for providing health care or assisting
in providing health care to the individual, and it is
not reasonably possible to collect, in a timely manner,
personal health information directly from the individual
or personal health information that can reasonably be
relied on as accurate.