Medical Record Keeping
The requirements for medical records are outlined in our Bylaw 23.1 Regulatory Bylaws. These standards apply to all medical records, including those for walk-in and telemedicine patients.
Proper record keeping is critical for continuity of care and follow up care, as well as for medico-legal purposes. Content, legibility and integrity of medical records are expected to meet the standards of the College. A medical record cannot be altered, except through specific processes, which are explained in the CMPA article The Medical Record: A Legal Document.
Other resources are:
- Electronic Records Handbook (clarifies some of the issues related to electronic records)
- CMPA online modules on Documentation and Charting
You are reminded of the privacy and confidentiality requirements relating to medical information.