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All patient-related documentation must be dated.Consultation reports, laboratory and diagnostic resultsmust be manually or electronically initialed and datedwhen they are reviewed. Every patient encounter mustbe documented and dated in the medical record.Where there will be more than one physician makingentries...

Maintaining a daily diary of patient appointments isrequired by the regulation4 and must include allprofessional encounters.While some physicians use the diary only to list thepatients seen each day, the daily diary can also containother useful information, such as the patient file andOHIP number, the patient...

The medical record must “tell the story” of the patientas determined by the physician in the circumstancesin which he or she saw the patient. The componentsnecessary to tell the story are set out in detail below.The record is not just a personal memory aid for theindividual physician who creates it. It must allowother...