New Standards for Patient Records Effective February 15

Standard of Practice for Documentation in Patient Records and Standard of Practice for Maintenance of Patient Records

The Patient Records Standard was updated to reflect already prevailing standards of practice in the profession, continuing modernization in the health care system, and the predominant use of digital platforms for patient records among members.

The current Patient Records Standard has been divided into two new Standards; one that addresses documentation in patient records, and a second that addresses requirements for maintenance of patient records.

Significant factors considered included:

• The association between substandard documentation and poor delivery of care that has been recurrently observed within CPSM’s Complaints and Investigation Department and the Quality Department.
• Situations that compromise patient access and copying rights, including disputes respecting possession and control of patient records that arise when group practices dissolve, and incidents of abandoned patient records when members leave a practice.

Additions made to the new Standards that address these factors include the following requirements:

• CPSM members maintain a cumulative summary of care to support tracking longitudinal care in outpatient practice.
• The need for Maintenance Agreements respecting patient records with specific requirements for members in group practices and other situations where responsibilities must be clarified.
• A requirement for members to have a plan in place to mitigate the risk of patient records being abandoned.

Read the full Standards: 

Standard of Practice for Documentation in Patient Records

Standard of Practice for Maintenance of Patient Records