Timing of the Events

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

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OHIP Documentation Requirements

OHIP Documentation Requirements

OHIP and Ministry of Health and Long-Term Care
(MOHLTC) requirements may change over time and
physicians should stay abreast of any changes through
OHIP and Ontario Medical Association (OMA)
information sources.
Physicians must understand their obligations under
the Health Insurance Act and the OHIP Schedule of
Benefits. Section 37.1 of the Health Insurance Act,
which deals with record keeping, is attached as
Appendix C.
Good records demonstrate that a service was provided
to the patient and establish that the service provided
was medically necessary. It is, therefore, imperative
that physicians maintain accurate and comprehensive
records, in order to receive payment for their services.
Any questions that physicians may have regarding the
OHIP Schedule of Benefits should be directed to the
appropriate local branch of OHIP or the Provider
Services Branch of the MOHLTC.

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The Daily Diary of Appointments

The Daily Diary of Appointments

Maintaining a daily diary of patient appointments is
required by the regulation4 and must include all
professional encounters.
While some physicians use the diary only to list the
patients seen each day, the daily diary can also contain
other useful information, such as the patient file and
OHIP number, the patient complaint or health problem,
and information related to the complaint or problem.
Recording information relating to the patient complaint
or problem will facilitate the task of billing OHIP.

Chronological and Systematic
It is strongly recommended that all materials in the
patient chart be organized in a chronological and
systematic manner.

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Comply with all Legal Requirements

Comply with all Legal Requirements

The medical record is a legal document which records
events and decisions that help physicians manage patient
care. A physician following the recommendations in this
policy will be in compliance with the record keeping
requirements of the College and requirements set out in
the Ontario Regulations made under the Medicine Act
(referred to in this policy as the “regulation”).2 The regulation
is included at Appendix A.
Many physicians are also associated with institutions
or facilities that may have their own record keeping
requirements. Physicians to whom this applies should
investigate and be familiar with those legal obligations
that may arise in the Public Hospitals Act, the Long-
Term Care Act, or the Independent Health Facilities Act.
Other legislation, such as the Mental Health Act and
the Personal Health Information Protection Act
(PHIPA)3 also has an impact on medical records,
either on what is in them or to whom they may be
transferred. These will be referred to in more detail in
the applicable sections below.

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Continuity and Quality in Medical Care

Continuity and Quality in Medical Care

The medical record must “tell the story” of the patient
as determined by the physician in the circumstances
in which he or she saw the patient. The components
necessary to tell the story are set out in detail below.
The record is not just a personal memory aid for the
individual physician who creates it. It must allow
other health care providers to read quickly and understand
the patient’s past and current health concerns.
It is not expected, however, that all patients will
always be able to read and understand their medical
records. Medical records may contain abbreviations
and terminology unique to the health care professions.

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PRINCIPLES of Medical Records

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.

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