Be aware of deficiencies in medical record keeping
The most frequent deficiency found by peer assessors engaged in medical practice assessments is substandard recorded care. Since 2013, the Physician Practice Enhancement Program (PPEP) has conducted over 1,200 assessments, which included both peer practice and multi-source feedback components. In 2013, the program found that 18% of physicians were found to have medical record deficiencies that prompted the Medical Practice Assessment Committee (MPAC) to recommend remediation. Remedial activities can include attendance at the College’s Medical Record Keeping for Physicians workshop, and/or the requirement to submit evidence of improved recorded care over a period of time.
The core requirement for medical records is set out in the Health Professions Act and in the College’s professional standard entitled Medical Records.
A medical record must:
- be written in English
- explain the reason for the visit
- provide the history and record of any examination, investigations, diagnoses, treatments and medications
- include a follow-up plan
The MPAC also sets best practice requirements, which in the case of family practice would include the use of the cumulative patient profile (CPP), allergy precautions and consideration for a differential diagnosis. With the evolution of the electronic medical record, the frequent legibility concerns seen in the past are being replaced with concerns related to truncated clinical notes as a result of poor keyboarding skills, and lack of technical competency and fluency.
The College addresses medical record requirements from its mandate to ensure patient safety by requiring evidence of an intellectual footprint that allows for continuity and transfer of care. Ensuring good patient care should always be at the forefront of daily clinical practice; however, the risk-adverse registrant may well wish to consider other questions:
- Will your medical records support you in defending your clinical actions when confronted with a medical-legal action?
- Will your medical records withstand the scrutiny of the Billing Integrity Program whose audit decision outcome is primarily based on the degree of documentation to support billing as set out in the Medical Services Commission’s payment schedule.