Indicator Group 10

Content of medical records

Records are sufficient to meet the requirements for describing and supporting the management of health care provided

Audit of medical records in accordance with CPSO guidelines - A guide to medical record keeping practices 2002

• The practice describes the audit of medical records
• Medical records chosen for audit show evidence of random selection
• The last entry in the record is less than 12 months old

A report of the audit findings is prepared by each family physician

• Reports prepared by each family physician in the practice
• Reports should specifically address every lapse in legal or essential information, as well as non-essential items that are important in the context of the practice
• Reports should identify opportunities and a plan for improvement
• Assess the practice�s ability to identify problem areas in record keeping and the effectiveness of processes for improvement
• Identify all significant problems with the records
• Plan any changes made as a result of discovering problems
• Identify how changes were implemented

The practice maintains a daily diary of appointments

• Maintaining a daily diary of patient appointments is a requirement of the recordregulation. The daily diary must include all professional encounters.
• There is a system to document and follow up on missed appointments

There is a patient record system

• The practice describes how each patient record includes results of all examinations and a list of investigations ordered at each visit
• Each patient record includes medication prescribing decisions made at each visit
• Patient record is legible
• Patient identity is clearly evident on each page of the record

The practice makes proper use of the Cumulative Patient Profile (CPP)

• Each patient record includes a cumulative and up-to-date list of problems
• Each patient record includes a cumulative and up-to-date list of medications
• There is a designated place for recording of drug allergies and adverse drug reactions in the chart

Telephone conversations are identified and the content recorded in the medical records

• The practice provides a register of telephone calls
• There is an audit of records to ensure that the telephone conversations are recorded

Notification to patients of recalls, results, referrals and other contacts are recorded in the medical records

• The record audit shows how the notification to patients was made and all actions (recalls, results, referrals, other contacts) are recorded

Clinical management decisions made outside the visit are routinely recorded

• All clinical decisions made about results are recorded in the patient notes, including the person who made the decision recorded and whether the patient was notified

Further Information for Indicator D.10.1

CPSO Policy - Medical Records

CPSBC - Common Office Observations and Deficiencies

Telephone Nursing Practice Guidelines

CPSO Peer Assessment

JAMA Article � Missing clinical information during primary care visits