Thank you for taking the opportunity to provide feedback on our draft Standard of Practice.
  
Your input will inform the Standard of Practice and ensure that it:
  • reflects current practice issues,
  • embodies the duties of medical professionalism, and
  • is consistent with the College’s mandate to act in the public interest.
 
Please note: All feedback collected through this survey is anonymous.

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* 1. Which best describes you? (select all that apply)

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* 2. Do you author medical records?

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* 3. Are you a custodian of medical records?

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* 4. This standard has been modified to state:

Physicians must maintain or contribute to a medical record for each patient they have assessed, treated, or provided consultative services. To ensure the accuracy of records and access to records by other treating healthcare providers, physicians must create records as close in time as practicable with their interaction with the patient.

Do you support this policy change?

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* 5. The standard has been modified to state:


When documenting in a patient’s medical record, all physicians must ensure the following information is recorded in a legible format:
  1. the full name and date of birth of the patient;
  2. the full name of the patient’s legal representative or substitute decision maker, if applicable;
  3. the patient’s medical care plan (MCP) number or extra-provincial healthcare plan number, if applicable;
  4. the patient’s mailing address and preferred contact information;
  5. the name of the referring healthcare provider, if applicable;
  6. the date of the professional encounter with the patient and, where relevant, the time of the encounter;
  7. a comprehensive record detailing the professional encounter, including, where relevant:
    • the patient’s presenting concerns and relevant history;
    • the findings of any examinations performed or requestioned, including pertinent negatives;
    • any diagnosis/provisional diagnosis made;
    • investigations ordered;
    • a description of each drug or other treatment prescribed or administered, including prescribed dosage and duration;
    • particulars of any referral(s) made by the physician;
    • any medical advice given; and
    • any additional details that may be useful to future healthcare professionals who may review the medical record.
  8. written consent forms, if applicable; and
  9. the results/reports of investigations or diagnostic imaging ordered, including the date received by the physician’s office, the date reviewed by the physician, and the date and manner the information was communicated to the patient.
Do you support this policy change?

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* 6. This standard has been modified to state:

Physicians who provide primary care to patients must also ensure the following information is included in the patient’s medical records:

  1. copies of consultant reports, operative reports, discharge summaries and other information created by other physicians or healthcare professionals which is relevant to the patient’s medical care.
  2. a cumulative patient profile, contextual to the physician-patient relationship, detailing:
    • current medications and treatments;
    • allergies and drug reactions;
    • medical history and ongoing health conditions;
    • risk factors;
    • family medical history;
    • health maintenance plans (e.g., immunizations, screening tests);
    • contact person in case of emergencies; and
    • date the cumulative patient profile was last updated.
  3. chronic disease flow sheets, where applicable.
Do you support this policy change?

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* 7. This standard has been modified to state:

Physicians may alter a medical record to ensure its accuracy and completeness. Where it is necessary to alter a medical record, physicians must clearly identify the alteration and the date the alteration was made.

When removing incorrect information from a record:
  1. the original record must be clearly labeled as incorrect; and
  2. the date the record was altered must be clearly indicated.
When adding new information to a record:
  1. the new information must be clearly identified as an addition to the original record; and
  2. the date the record was altered must be clearly indicated.
Do you support this policy change?

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* 8. This standard has been modified to state:

[For physicians who act as custodians of records]

While the information contained within a medical record belongs to the patient, the person or organization responsible for the creation and overall management of the record is considered the custodian.

Physicians who act as custodians of medical records are responsible for ensuring that they are maintained, stored, transferred, retained, and destroyed in accordance with this Standard of Practice and the requirements set out in the Personal Health Information Act.

In situations where a physician is creating medical records in a private group practice, a data‑sharing agreement must be in place to address the issue of defining the custodian of the record and determining how access to the records and transfer of custodianship can occur.

Do you support this policy change?

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* 9. This standard has been modified to state:

[For physicians who act as custodians of records]

Record management protocols must be in place to regulate who can gain access to the medical record and what they can do, according to their role and responsibilities.

For electronic medical record systems, physicians must ensure that each authorized user has a unique ID and password. Physicians must not share their unique credentials and password for electronic medical record keeping systems.

Physicians must ensure that all individuals who have access to the medical record are bound by appropriate confidentiality agreements and are educated on the relevant subsections of the Personal Health Information Act.

Do you support this policy change?

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* 10. This standard has been modified to state:

[For physicians who act as custodians of records]

Physicians must ensure that medical records are retained for a minimum of:
  • 10 years following the date of last entry into the record for adult patients.
  • 10 years after the date on which the patient reached the age of 19 years for pediatric patients.
If a physician is aware that a medical record contains personal health information that is the subject to a request for access or has been given notice that the record may be relevant to any investigation, inquiry, or proceeding, the physician must maintain the record until the required access or transfer has been provided.

A copy of the physician’s daily schedule, appointment sheets, or equivalent should be retained for a period of 10 years. 

Do you support this policy change?

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* 11. This standard has been modified to state: 

[For physicians who act as custodians of records]

A physician may transfer original medical records to another custodian or a bonded record retention facility for the purposes of secure storage, provided that:
  1. a written contract is in place with the accepting custodian or record retention facility that ensures the requirements of this Standard of Practice and those outlined in the Personal Health Information Act will continue to be met; and
  2. the physician notifies the College of the new location of the records.
In the above circumstances, the physician remains the custodian of the records.

A physician continues to act as the custodian of a medical record until such time that custody and control has passed to another person who is legally authorized to hold the record. In circumstances where a physician legally transfers custody and control to a successor custodian, the physician must make reasonable efforts to notify patients of the transfer.


Do you support this policy change?

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* 12. This standard has been modified to state: 

[For physicians who act as custodians of records]

Following the applicable period of retention, medical records can be destroyed. When destroying medical records, physicians must ensure that the record cannot be reconstructed or retrieved.

It is only necessary to retain one original medical record. As such, if the information contained in a paper record has been fully transitioned to an electronic medical record, the paper record can be destroyed.

Do you support this policy change?

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* 13. Please share your comments and/or concerns about the draft Standard of Practice.

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* Please feel free to answer the following additional questions regarding your demographics.

Information collected will allow us to ensure we have reached a diverse group of survey respondents and identify any trends. 

Optional Question 1: In which NL Health Services zone or geographic region do you reside?

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* Optional Question 2: How do you identify?

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* Optional Question 3: Which category includes your age?

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