winter 2013

p r a c t i c e   m a n a g e m e n t
From Peer to Peer

Stock Photo



The evaluation of patient records makes up a major portion of the Atlantic Provinces Medical Peer Review assessment process. It is, therefore, essential for us to have some understanding of what our standards for patient records are.

By Jean-Marie Auffrey, MD

The evaluation of patient records makes up a major portion of the Atlantic Provinces Medical Peer Review (APMPR) assessment process. It is, therefore, essential for us to have some understanding of what our standards for patient records are or should be — and for us to be able to communicate those standards to our assessors, the physicians being assessed, and others in our profession.

Many of us would agree that we “know a good medical record when we see it.” If, however, we were asked to justify our positions, it would be difficult to articulate exactly what has shaped our opinions, and more difficult still to communicate the specifics to someone seeking guidance.

For an APMPR assessor to explain to a physician that they need to be able to tell from a record: “why the patient came, what was found and what was done” is really only part of the story. We believe that an adequate patient record must also be an accurate reflection of the intellectual process which occurred during the office visit.

In an article published by the Ontario College of Physicians & Surgeons, the four primary purposes served by a medical record were noted:

  1. It saves the physician time in recalling details of the patient’s history, and allows the physician to monitor the progress of a patient’s treatment.

  2. Colleagues and locums can use the record when called upon to treat the patient.

  3. It is useful for medical-legal reference, such as enabling the physician to provide a patient with a comprehensive report relating to an illness or injury. It can also help a physician called upon to present evidence in court.

  4. The record can be invaluable to the physician when responding to inquiries regarding the treatment of a patient from Medicare, a provincial licensing authority, or in a legal action against the physician.

In general, a patient record should stand on its own as a chronicle of patient history and care, providing the reader with an understanding of how and why certain decisions were made — the intellectual process noted above. The overall content of a quality record should provide a clear and accurate guide which will enable an incoming physician to assume the care of that patient without hesitation and without difficulty.

The specific contents of a quality record are harder to establish, but the minimum information required includes:

  • the name, address, date of birth and sex of the patient;

  • the date of each visit in which the patient is seen;

  • an adequate patient history for each visit;

  • the particulars of each physical examination, including the positive and negative physical findings;

  • a diagnosis or provisional diagnosis;

  • investigation orders and the results; and,

  • the treatment prescribed, any referrals made, and any plan of follow-up.

It is also recommended that the identity of the patient be clearly evident on each component of the file; and that a system (such as initialling) should be in place to ensure that all results of investigations, letters from consultants and so on, are seen by the physician before being filed. Drug allergies should be clearly “flagged” on the file; and, in pediatric cases, an updated pediatric growth chart is recommended.

While it is not mandatory, APMPR supports and strongly recommends the use of Cumulative Patient Profiles (CPPs) and the Subjective Objective Assessment Plan (SOAP) format. It is our opinion that these represent the most appropriate way to document medical information in both general and specific terms. None of the above will have any bearing at all if the record is not legible. Clearly handwritten, printed or typed notes are absolutely essential.



Site Map | DisclaimerCredits | Webmaster
© Newfoundland and Labrador Medical Association (NLMA)




MDLink to primary care

Patient Blood Management: A patient oriented approach to best-practice in Transfusion Medicine

New concussion guidelines released, new CMA CME on concussions

Make sure your investment portfolio is tax efficient

NLCHI launches HEALTHe NL Viewer

End-of-life issues dominate CMA debate, an Integrated Palliative Approach to Care launched

From Peer to Peer

Exciting new changes to Memorial University’s MD program

When the odds aren’t in your favour

National Physician Survey Flags a Lack of Patient Care Resources and Workforce Planning

Action on bike helmet legislation needed in time for 2014 season

Discipline of Family Medicine an integral part of primary care in Newfoundland and Labrador

Former NLMA President passes away

CMA members have access to $395 clinical tool

Decorations, presents and the tax man

MUN Med Gateway

CMA updates return-to-work policy

de Souza Institute expands curriculum to all health care professionals that treat cancer patients

‘That’s our focus’

Chronic Disorders Network Core launches new web portal

‘First of their kind’ Food addiction and the development of human obesity

Doctors in the News

In Memoriam

Clinical Practice
CMA News
Common Revolt Against Paperwork (C.R.A.P.)
Doctors in the News
Executive Director's Message
General Council
Government Relations
Health Administration
Health Policy
Health Promotion
Health Technology
In Memoriam
Information Technology
Job Action
Physician Wellness
Practice Management
Primary Care Renewal
Resident's Corner
NLPDP Behind the Scenes - Winter 2014 (PDF)
Winter 2013
Summer 2013
Spring 2013
Winter 2012
Fall 2012
Summer 2012
Spring 2012
Winter 2011
Fall 2011
Summer 2011
Spring 2011
Winter 2010-11
Fall 2010
Summer 2010
Spring 2010
Winter 2009
Fall 2009
Summer 2009
Spring 2009
Winter 2008
Fall 2008
Summer 2008
Spring 2008
Winter 2007
Fall 2007
Summer 2007
Spring 2007
Winter 2006
Fall 2006
Summer 2006
Spring 2006
Winter 2005
Fall 2005
Summer 2005
Spring 2005
Winter 2004
Fall 2004
Summer 2004
Spring 2004
Winter 2003
Fall 2003
Summer 2003
Spring 2003
Fall/Winter 2002
A connected group or series; a bond, a connection.

Nexus is published quarterly for Newfoundland and Labrador's physicians. It is a forum for the exchange of views, ideas and information for members.