Medical Record Tips

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Administrative burden is eating away at the time physicians want to spend with patients. In three articles, we address the efforts being made to put patients before paperwork, clarify the obligation of specialists and family physicians, and answer some FAQs about medical documentation.

Physician burnout is a reality, and administrative duties like medical records documentation can feel burdensome and create further stress.

Below are FAQs about medical record-keeping and CPSO’s Medical Records Documentation policy that can help clarify your obligations.

  1. Am I allowed to use (pre-populated) templates when documenting in the medical record?
    Yes. CPSO supports the use of digital tools or applications that can assist physicians in fulfilling their record-keeping obligations. What is required is that they are used properly, and records remain accurate and complete. When using templates, especially those that are pre-populated, carefully reviewing records and removing any information that does not reflect the patient or their experience is important to ensure accuracy. The use of templates that permit free text documentation is one way to ensure records are accurate and complete.

  2. Do I have to document using the SOAP method?
    No. The Medical Records Documentation policy does not require a specific documentation approach. Instead, it sets out broad principles that must be met and a number of high-level elements that must be captured. CPSO recognizes the Subjective Objective Assessment Plan (SOAP) format for documentation as a best practice, but it is not required.

  3. Do I always have to document consent for treatment?
    No. The Consent to Treatment policy requires physicians document consent to treatment in certain higher-risk circumstances. (Please see the policy for a list of specified circumstances where documentation is required.) In all other circumstances, documentation is recommended, but not required. Physicians may also use their discretion as to the information and level of detail that should be included regarding consent to treatment, with the level of detail being proportionate to the specific condition(s) and circumstances.

  4. Do I have to use flow sheets to document chronic conditions?
    No. The Medical Records Documentation policy does not set out requirements for the use of specific practice tools. The Advice to the Profession document recommends the use of flow sheets for documenting chronic conditions as a best practice, but this is not a requirement in the policy. 

  5. Can I use a scribe to document on my behalf?
    Yes. One way to help manage documentation could be through the use of a medical scribe. Depending on the approach (e.g., who is doing the transcribing, what information is being transcribed), physicians can keep the following considerations in mind: 
    • Physicians are responsible for reviewing the transcribed records to ensure accuracy and completeness.
    • While documentation is not a controlled act as per the CPSO’s Delegation of Controlled Acts policy, physicians are responsible for ensuring staff documenting on their behalf have the appropriate training and skills to do so and are supervised
    • Patient consent must be obtained to allow the scribe to assist with the documentation of care.
    • Physicians should follow any applicable hospital or organizational policies or guidance related to the use of scribes.