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Approved by Council: November 2000 Policies of the College of Physicians and Surgeons of Ontario (the “College”) set out expectations for the professional conduct of physicians practising in Ontario. Together with the Practice Guide and relevant legislation and case law, they will be used by the College and its Committees when considering physician practice or conduct. Within policies, the terms ‘must’ and ‘advised’ are used to articulate the College’s expectations. When ‘advised’ is used, it indicates that physicians can use reasonable discretion when applying this expectation to practice. Additional information, general advice, and/or best practices can be found in companion resources, such as Advice to the Profession documents. DefinitionsCumulative Patient Profile (CPP) or equivalent patient health summary: A summary of essential information about a patient that includes critical elements of the patient’s medical history and allows the treating physician, and other health care professionals using the medical record, to quickly get a picture of the patient’s overall health. Policy
Principles for Documenting the Patient Encounter
Timing of Documentation
Use of Templates
What to Document: Medical Records Content
CPP or Equivalent Patient Health Summary
Clinical Notes
Telephone and Electronic Communications with Patients
Corrections to Medical Records
Endnotes1. Personal Health Information Protection Act, 2004, S.O. 2004, c.3, Sched. A (hereinafter PHIPA); Part V of the General, Ontario Regulation 114/94, enacted under the Medicine Act, 1991, S.O. 1991, c. 30 (hereinafter Medicine Act, General Regulation); General, Ontario Regulation 57/92, enacted under the Independent Health Facilities Act, R.S.O.1990, c.1.3 (hereinafter IHFA, General Regulation); Hospital Management, Regulation 965 enacted under the Public Hospitals Act, R.S.O. 1990, c.P.40 (hereinafter Public Hospitals Act, Hospital Management Regulation); Health Insurance Act, R.S.O.1990, c. H.6 (hereinafter Health Insurance Act). 2. Additional expectations for record-keeping are set out in other College policies, including Medical Records Management, Transitions in Care, Closing a Medical Practice, Protecting Personal Health Information, Managing Tests, Consent to Treatment, and Prescribing Drugs. 3. Medicine Act, General Regulation, s. 18(3). 4. There are circumstances where a physician’s records are transcribed on the physician’s behalf. In these circumstances the notation “dictated but not read” is often used to signify that that the physician has not yet reviewed the transcription for accuracy. The Canadian Medical Protective Association’s article "Dictated but not read": Unreviewed clinical record entries may pose risks sets out advice on how to mitigate risks when dictating medical record entries or reports. 5. Section 18(3)(b) of Medicine Act, General Regulation requires records to be kept in a systematic manner. 6. Additional guidance related to appropriate documentation is set out in the Advice to the Profession: Medical Records Documentation document. 7. Section 17.4 (5) of the Health Insurance Act requires records to be prepared promptly when the service is provided. Additional guidance on best practices for documentation completion is set out in the Advice to the Profession: Medical Records Documentation document. 8. Some components of the medical record have specific requirements for completion. Please see the College’s Transitions in Care policy for expectations related to completing and distributing discharge summaries and consultation reports. 9. For additional guidance related to templates please refer to the Advice to the Profession: Medical Records Documentation document. 10. Section 18(1) paragraphs 1 and 2 of the Medicine Act, General Regulation require physicians to make records for each patient containing the patient’s name, address, date of birth and Ontario health number, where applicable. 11. Documenting the date of the professional encounter is a requirement under s.18 of the Medicine Act, General Regulation; s. 19(2) of the Public Hospitals Act, Hospital Management Regulation requires each entry in a medical record to indicate the date on which it was made. 12. A sustained physician-patient relationship is physician-patient relationship where care is actively managed over multiple encounters. 13. There may be variations in content and format of the CPP or equivalent patient health summary based on the physician’s practice area and the nature of the physician-patient relationship (i.e., whether there is a sustained physician-patient relationship). 14. For a consultation, s.18 (1) of the Medicine Act, General Regulation requires medical records to contain indication of the name and address of the primary care physician and of any health professional who referred the patient. 15. For additional guidance regarding information that must be contained in a referral note and consultation report, please refer to the College’s Transitions in Care policy. 16. Guidance for documenting operative and procedural notes is set out in the Advice to the Profession: Medical Records Documentation document. 17. Sections 19(4) and 19(5) of the Public Hospitals Act, Hospital Management Regulation set out a number of additional requirements for documentation in a hospital setting. Physicians who practise in hospitals are advised to refer to the regulation for information about the specific requirements. 18. For expectations related to e-mail communications with patients please refer to the College’s Protecting Personal Health Information policy. 19. These requirements are reflective of PHIPA, s. 55(10). 20. With an electronic record, this can be achieved by using a digital strikeout (e.g., “track changes”) or where this is not possible, an addendum explaining the necessary changes. 21. PHIPA, s. 55 (10). 22. PHIPA, s. 55(11). For additional requirements pertaining to corrections, please refer to s. 55 of PHIPA. Which of the following is usually included in medical history?A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests. It may also include information about medicines taken and health habits, such as diet and exercise.
What are the 4 components of medical history?It usually contains the patient's health information (PHI) which includes identification information, health history, medical examination findings and billing information.
What is included in medical history quizlet?Past illness, treatments, operations, accidents, physical defects, allergies, childhood diseases, immunizations. Year or age event is recorded. Past operations - type of surgery, date or age. Medications past or present.
What are four types of clinical information found in the history and physical section of a patient record?They contain a patient's health information (which is also referred to as PHI) that includes health history, billing information, identification information, and findings of medical examinations.
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