The Medical Record

The medical record is a powerful tool that allows the treating physician to track the patient’s medical history and identify problems or patterns that may help determine the course of health care.
The primary purpose of the medical record is to enable physicians to provide quality health care to their patients. It is a living document that tells the story of the patient and facilitates each encounter they have with health professionals involved in their care.
In addition to telling the patient’s story, complete and accurate medical records will meet all legal, regulatory and auditing requirements. Most importantly, however, they will contribute to comprehensive and high quality care for patients by optimizing the use of resources, improving efficiency and coordination in team-based and inter professional settings, and facilitating research. This is achieved in the following ways:

• Quality of care: Medical records contribute to consistency and quality in patient care by providing a detailed description of patients’ health status and a rationale for treatment decisions.
• Continuity of care: Medical records may be used by several health practitioners. The record is not just a personal memory aid for the individual physician who creates it. It allows other health care providers to access quickly and understand the patient’s past and current health status.
• Assessment of care: Medical records are fundamental components of:
  • external reviews, such as those conducted for quality improvement purposes (e.g., the College’s Peer Assessment Program and Independent Health Facilities Program),
  • investigations (such as inquiries made by the Coroner’s Office, and College investigations),
  • billing reviews (records must be properly maintained in order for physicians to bill OHIP for services), ¹ and
  • physician self-assessments, whereby physicians reflect on and assess the care they have provided to patients (for instance, through patterns of care recorded in the EMR).
• Evidence of care: Medical records are legal documents and may provide significant evidence in regulatory, civil, criminal, or administrative matters when the patient care provided by a physician is questioned. The legal requirements for medical records are set out in the Ontario Regulations made under the Medicine Act, 1991 (referred to in this policy as the “Regulation” and attached at Appendix A). Other legislation that has an impact on medical records is listed under “Legislative References” at the beginning of this policy.

This policy explains how medical records must be kept, outlining general requirements and considerations about the collection, use, storage, and disclosure of patients’ personal health information, with respect to both paper and electronic records. It outlines requirements with regard to access and retention periods to ensure continuity of care for patients. The policy concludes by listing requirements for the contents of medical records, explaining what must be included in records and how it must be documented.