Health Professionals, Medical Records & Documentation
Medical and Professional Recordkeeping and Documentation
Health Professionals in Ontario are expected to keep proper medical records relating to patient care and treatment. The legislation which governs most health professionals in Ontario[1] includes a professional misconduct regulation which states that those who fail to keep patient and medical records as required by the standards of the profession are guilty of an act of professional misconduct.[2] In addition to legislation, many regulatory colleges have policies or standards that outline the importance of keeping proper and accurate medical records and the requirements of health professionals to do so.
In our legal practice, we hear from clients that maintaining detailed records is challenging because of the time commitment required to document specifics and details, particularly after a long day of seeing patients. It is true that record keeping can be onerous and can interfere with the flow of the day. However, there are many benefits for maintaining well documented records. For example, if a patient makes a complaint to the health professional’s regulatory body about the treatment or care received, the patient record can serve as corroboration or a contemporaneous account of the events, which a health professional can point to, and which a College Committee, such as the Inquiries, Complaints and Reports Committee (ICRC) or the Discipline Committee, can refer to and rely upon when making a determination. Accordingly, properly kept records can support the health professional’s version of events.
A recent case before the Health Professions Appeal and Review Board (HPARB)[3] highlights the importance of proper recordkeeping.
HPARB Decision on the Importance of Recordkeeping
In this case HPARB was asked to review the decision of the Complaints Committee of the College of Veterinarians of Ontario (the “Committee”) to issue advice to the registrant. The complaint to the College alleged, in addition to breaches in the standard of care, that the registrant’s medical records contained inaccurate details and typographical errors, which indicated carelessness and a general lack of focus.
The Committee acknowledged that while errors can occur, the registrant’s medical records appeared to be inadequate in some areas, including certain aspects of the patient’s clinical status and documenting client communication about the patient’s condition. For example, a notation in the medical record indicated that certain observations of the patient were not discussed with the client. The Committee was troubled by the lack of documentation of client communication in the record and explained that the registrant is expected to ensure that all client communication is appropriately entered in the medical record and that the record documents the client’s informed consent and the understanding of the client.
Given the deficiencies in the medical record and the general record keeping practices of the registrant, the Committee issued advice to the registrant to include information that must be contained in the medical record, as outlined in the legislation[4] and the Professional Practice Standard. The registrant must include information such as the registrant’s thought process, decisions, judgments, actions and interaction with others, each of which has an impact on patient outcomes. The Committee noted that it takes into consideration the medical records and the documentation of the events to support the care provided. Specifically, the Committee advised the registrant of the following:
Comprehensive medical records are essential to the health and well-being of every patient. Keeping complete medical records facilitates good patient care, allows a subsequent practitioner to understand the patient’s condition and the basis for the current treatment, provides a method of communication with fellow veterinarians and satisfies ethical and regulatory obligations for managing appropriate records. In the event that care is questioned in the future, comprehensive medical records provide a clear account of events as they occurred, and the services rendered. Client communication is a crucial component of medical records and documents discussions with client about the medical status”.
In its review of the Committee’s decision to offer advice and recommendations to the registrant on recordkeeping, HPARB confirmed this decision.
Tips for Maintaining Proper Records
Carve out time each day to document the patients or clients seen that day while the information is recent and fresh in one’s mind;
Document conversations with patients that are relevant to treatment and care, and not just that a conversation took place. Document the nature of the conversation, what was discussed and any questions the patient asked (and how they were answered).
Short hand is acceptable but ensure it is easy to is easy to understand and captures the treatment that took place.
Include dates of treatment or discussions with patients and ensure these details are accurate.
When obtaining patient’s consent, include details of the conversation with the patient and document what the risks and benefits of treatment are (and not just that there are risks and benefits to treatment), questions the patient asks and answers provided. Document whether the patient understood the discussion and agreed to proceed with treatment. Documenting consent discussions is as important – if not more - than asking patients to sign and date a template consent form.
Never, ever alter a chart note.
If you think of something later or need to enter a note into the patient record sometime after the encounter, mark it “late entry” and put the date the chart entry is made.
Consider reviewing policies and standards of regulatory colleges and/or contacting regulatory colleges or associations for courses or workshops on appropriate and proper record keeping courses to fully understand obligations with record keeping.
When in doubt, or if facing complaints or investigations, consult with legal counsel for advice and recommendations on implementing proper, accurate and appropriate recordkeeping practices.
[1] Self-governing health professionals regulated by the Regulated Health Professions Act, 1991, SO 1991, C.18.
[2] See for example O.Reg. 384/00 under the Social Work and Social Service Work Act, 1998 s. 19-22; O. Reg. 749/93 under the Audiology and Speech-Language Pathology Act, 1991, s. 19-22; O.Reg. 114/94 and O. Reg. 856/93 under the Medicine Act, 1991; O.Reg. 799/93 under the Nursing Act, 1991, s. 13.
[3] Chire v. French, 2023 CanLII 55 (ONHPARB).
[4] Veterinarians Act, RSO 1990, c. V. 3.