Each province and legislative jurisdiction has its own requirements, both legal and professional, for creating, maintaining and storing medical records. One key point which is common to all jurisdictions is that the records are legible. Another is that keeping good medical records is part of providing good medical care.
The College of Physicians and Surgeons of Ontario (CPSO) writes regarding ‘Clarity and Legibility’:
The regulation requires that medical records be legible1. Furthermore, the College expects that the records can be interpreted by the average health care professional. If there is difficulty with the legibility of the records, an alternate means of note taking should be considered (e.g., voice dictation, electronic medical records, or handwriting recognition software)2.
Using conventional medical short forms is permissible. However, the meaning should be readily available to a health care professional reading the record.
There is also the requirement of communicating appropriately with other health care providers. The CPSO notes:
The need for good communication also applies between health professionals. Multidisciplinary care is a fact of life in our health care system and the medical record serves as the conduit of information shared between health care providers. Continuity of care can only be preserved if the flow of information remains uninterrupted and intact3.
The CPSO provides a tool for the self-evaluation of proper documentation of your medical records, which is part of the protocol of their peer assessment activities. Complete information regarding this self-evaluation tool Appendix B: Self-Evaluation: Assess Your Own Medical Records) for Ontario Physicians may be viewed at http://www.cpso.on.ca/policies/policies/default.aspx?ID=16864. It’s a way of identifying areas of strengths and weaknesses in a physician’s practice.
If you find discrepancies in the way you are currently documenting your patient records, including their legibility, consider one of the alternative ways of note taking as recommended by the CPSO, including dictating your patient notes and having them transcribed by a medical transcription agency or provider.
One way to ensure that you are keeping adequate medical records is to dictate your reports in a timely fashion (after each patient visit or daily) and have them transcribed, either in-house or by a medical transcription agency. The medical records will be legible and will help to facilitate good communications with other health care providers.
1 O. Reg. 114/94 section 18(3): “The records required by regulation shall be, (a) legibly written or typewritten or made and kept in accordance with section 20….” (i.e., electronically).
2 Reference: http://www.cpso.on.ca/policies/policies/default.aspx?ID=1686 Dec 2010
3 Reference: http://www.cpso.on.ca/policies/policies/default.aspx?ID=1686 Dec 2010
4 “Appendix B: Self-Evaluation: Assess Your Own Medical Records” for Ontario Physicians may be viewed at http://www.cpso.on.ca/policies/policies/default.aspx?ID=1686
Check our medical transcription dictation tips next month to learn more.