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In settings such as walk-in clinics, single patient files must be created and all documentation for a single patient must be kept in that patients file. It is not appropriate to file by date. Collection, Use, and Disclosure of Information Physicians must always obtain the patients consent when collecting, using or disclosing personal health information.
Physicians are ultimately responsible for meeting the expectations set out in this policy and may assess their own medical record-keeping practices by answering the questions listed in Appendix C, which have been taken directly from a protocol used in the Colleges peer assessment activities. Scope, this policy establishes principles and requirements for all medical records.