What is Carlisle Medical Journal?

What is Carlisle Medical Journal?

Carlisle Medical Journal is a very unique, compact, and user friendly medical journal that can be used to assist anyone in organizing and recording their own medical history. The journal is divided into 7 customized sections. Each multi-colored tab contains the title for each section. The contents of the book fits into a three ring customized binder approximately 7" x 6". Simply fill in the blanks to record important information about your family medical tree; doctors and specialist information; medicines used; allergic reactions; appointments; medical test/ results; surgeries and hospital stays; and journaling your thoughts and experiences. Having access to all this information in one centrally located place can be very helpful to take with you each time you visit any doctor. It would also be helpful to a friend or relative during an emergency situation to have all of your medical history contained in one place.

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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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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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