medical records: online survey...

Medical Records: Online Survey Report

From the Preliminary Consultation on the Current Policy

September-December, 2017

Introduction

The College’s current Medical Records policy was released for external consultation between September-December, 2017. The purpose of this consultation was to obtain stakeholders’ feedback to help ensure that the policy reflects current practice issues, embodies the values and duties of medical professionalism, and is consistent with the College’s mandate to protect the public.

Invitations to participate in the consultation were sent to a broad range of stakeholders, including the entire CPSO membership, and a notice was posted on the CPSO website and social media platforms.

Feedback was collected via regular mail, email, an online discussion forum, and an online survey. In accordance with the College’s posting guidelines, all feedback received through the consultation is posted online.

This report summarizes only the stakeholder feedback that was received through the online survey.

Page 1 – http://policyconsult.cpso.on.ca/?page_id=9687

http://www.cpso.on.ca/Policies-Publications/Policy/Medical-Records

http://policyconsult.cpso.on.ca/?page_id=9701

http://www.cpso.on.ca/Footer-Pages/The-Consultation-Process-and-Posting-Guidelines

http://policyconsult.cpso.on.ca/?page_id=9701

Caveats

48 respondents initiated the survey, however, 7 failed to provide responses to any substantive questions (see Table 1). For the purposes of this report, these 7 surveys are considered incomplete, and have not been included.

Note: Participation in this survey was voluntary, and one of a few ways in which feedback could be provided. As such, no attempt has been made to ensure that the sample of participants is “representative” of any sub-population.

The quantitative data captured in this report are complete, and the number of respondents who answered each question is provided.

The qualitative data captured in this report are a summary of the general themes or ideas conveyed through the open-ended feedback. Where reported, stakeholder feedback to open-ended questions has been paraphrased.

Summary of surveys received n = 48

Complete or partially complete 41

85%

Incomplete 7

15%

Table 1: Survey status

Page 2 – Medical Records Online Survey Report – Dec 2017

Profile of Respondents

Do you live in…? n = 41

Ontario 40

98%

Rest of Canada 0

0%

Outside Canada 0

0%

Prefer not to say 1

2%

Are you a…? n = 41

Physician (incl. retired) 25

61%

Medical Students 0

0%

Member of the Public 9

22%

Other health care professional (incl. retired)

2

5%

Organization 1

2%

Prefer not to say 4

10%

The majority of survey respondents (61%) were physicians (Table 2).

Table 2: Respondent demographics

And nearly all survey respondents (98%) were residents of Ontario (Table 3).

Table 3: Respondent location


Part 1: Questions for Physicians

The following questions were posed to physicians to obtain information about them and their practices, and to assess their opinions on certain sections of the current policy.

As they did not require respondents to have read the current policy, the questions in this section were posed to all respondents who identified themselves as physicians.

Note: In some cases, in order to provide respondents with relevant context, additional detail was provided in the survey. For the sake of brevity, this additional contextual detail is not always reproduced in this report.


The majority of physician respondents (58%) were specialists.

Q4. “What kind of physician are you?”


42% 58% What kind of

physician are you?

Family Physician SpecialistBase: n = 26

Figure 1: Physician type

Open ended feedback regarding the kind of physician was received from 12 respondents:

• Paediatrics • Geriatrics • Ophthalmology • Cardiology • OB/GYN • Psychiatry • Full-time psychotherapy • Marital, family therapy and psychoanalysis • Comprehensive Family Medicine (including prenatal, delivery and postnatal

care)

This is a representative sample of the key feedback received.

Q4. “Comments regarding the kind of physician.”


Almost half of physician respondents (42%) stated they have both paper and electronic records.

Q5. “What type of medical records do you have?”


27% 31% 42% What type of medicalrecords do you have?

Paper Electronic Both paper and electronicBase: n = 26

Figure 2: Record type

The majority of physician respondents (72%) stated they use an Electronic Medical Record (EMR).

Q6. “Do you currently use either an Electronic Medical Record (EMR) or Electronic Health Record (EHR) in your practice?”


72% 6% 22% Do you currently useeither an EMR or EHR

in your practice?

Electronic Medical Record Electronic Health Record BothBase: n = 18

Figure 3: EMR/EHR use

The majority of physician respondents (67%) encountered specific challenges with the EMR and/or EHR.

Q7. “Have you encountered any specific challenges with the EMR and/or EHR?”


67% 33%

Have youencountered any

specific challengeswith the EMR and/or

EHR?

Yes NoBase: n = 18

Figure 4: EMR/EHR challenges

Q8. “If yes, describe the challenges you encountered with the EMR and/or EHR.”

Comments regarding the challenges physicians encountered with the EMR and/or EHR were received from 12 physician respondents:

• EMR can be slow. • Format difficult to read; interface is a challenge; not an easy system to use. • Access to out of office charts can be a challenge. • Can’t audit activities; data mining is a challenge. • Disrupts workflow/patient care if unstable network results in frequent

glitches/crashes, or during downtime/maintenance. • Lacks narrative that a written history provides; loses much of the individual

nuances contained in a narrative format. • CPP is extensive and comprehensive, but long. • Doesn’t communicate with any other EMR. • Duplication of results in the EHR because paper faxes are also sent.



The majority of physician respondents (57%) stated they have custody of all of their patients’ medical records.

Q9. “Do you have custody of your patients’ medical records (paper and/or electronic)?”


57% 21% 21%

Do you have custody of your patients’ medical records (paper and/or electronic)?

Yes, all Some NoBase: n = 24

Figure 5: Custody of records

The majority of physician respondents (69%) who have custody of all of their patients’ medical records are solo practitioners.

Q10. For physicians who indicated they have custody of all their patients’ medical records: “What kind of setting(s) are you practicing in where you have custody of your patients’ medical records (paper and/or electronic)?”


69% 31% What kind of

setting(s) are youpracticing in?

Solo Practice Hospital Clinic Family Health Team/Group Practice Walk-in ClinicBase: n = 13

Figure 6: Practice setting

Almost half of physician respondents (40%) who have custody of some of their patients’ medical records are solo practitioners.

Q11. For physicians who indicated they have custody of some of their patients’ medical records: “What kind of setting(s) are you practicing in where you have custody of your patients’ medical records (paper and/or electronic)?”


40% 20% 20% 20% What kind of

setting(s) are youpracticing in?

Solo Practice Hospital Clinic Family Health Team/Group Practice Walk-in ClinicBase: n = 5

Figure 7: Practice setting

40%

40%

20%

20%

Hospital

Clinic

Family Health Team / Group Practice

Walk-in Clinic

Commercial Storage Provider

Who has custody of your patients’ medical records?

Physician respondents who don’t have custody of some of their patients’ medical records reported that the records were in the custody of various entities.

Q12. For physicians who indicated they have custody of some of their patients’ medical records: “If you don’t have custody of your patients’ medical records (paper and/or electronic), who does?”


Base: n = 5


100%

20%

20%

Hospital

Clinic

Family Health Team / Group Practice

Walk-in Clinic

Commercial Storage Provider

Who has custody of your patients’ medical records?

All physician respondents (100%) who don’t have custody of their patients’ medical records reported that the records were in the custody of the hospital.

Q13. For physicians who indicated they don’t have custody of their patients’ medical records: “If you don’t have custody of your patients’ medical records (paper and/or electronic), who does?”


Base: n = 5


A slight majority of physician respondents (52%) experienced specific challenges in regards to medical records.

Q14. “Have you experienced any specific challenges in regards to medical records? For example, issues documenting the clinical encounter, securely storing records, retaining records, accessing/transferring records (with appropriate authorization), destroying records, etc.”


48% 52%

Have you experiencedany specific

challenges in regardsto medical records?

Yes No Don't knowBase: n = 23

Figure 10: Challenges with medical records

Q15. “If yes, please specify what those challenges were.”

Comments regarding the specific challenges physicians encountered with medical records were received from 11 physician respondents:

• Transfer of records is cumbersome. • Can’t see vital signs during transfer. • Unable to upload images; drawing on the chart or using narrative is time

consuming. • Most electronic systems are not user friendly and they take time to learn. • For paper records, the most frustrating challenge is lack of organization and

misfiled information. • Not enough time to diligently document patient encounters in a day. • Lengthy storage period is challenging for older paper records. • No mechanism to keep physicians up to date re: current expectations. • College requirements are a costly waste of time; the need to detail every

hour interferes with psychotherapy.



The majority of physician respondents (78%) do not use the Checklist (Appendix C).

Q16. “The current policy has a Self-Evaluation: Assess Your Own Medical Records Checklist attached as Appendix C to assist physicians review and evaluate their own medical records. Do you use this Checklist?”


22% 78% Do you use thisChecklist?

Yes NoBase: n = 23

Figure 11: Appendix C

Almost half of physician respondents (44%) think the Checklist (Appendix C) is helpful.

Q17. “In your view, is this Checklist helpful?”


44% 17% 39% In your view, is thisChecklist helpful?



The majority of physician respondents (60%) don’t think there is anything missing from the Checklist (Appendix C).

Q18. “In your view, is there anything missing from the Checklist that should be included in the next iteration?”


30% 60% 10%

is there anythingmissing from the

Checklist that shouldbe included in the

next iteration?



Q18. “Comments.”

Comments regarding whether there is anything missing from the Checklist that should be included in the next iteration were received from 3 physician respondents:

• Greater detail regarding maintenance of CPP. • Specific reference to mental health symptoms and clinical findings. • My goals; patient presenting with minor ailment - addressed properly, not

taking BP or diabetes medication, or non compliant - need to address.



Just under half of physician respondents (48%) don’t know if the Flow Sheets listed in Appendix F are helpful, but 39% of physician respondents think they are helpful.

Q19. “In your view, are these Flow Sheets helpful?”


39% 13% 48% In your view, are

these Flow Sheetshelpful?


Figure 14: Appendix F

The majority of physician respondents (70%) do not use all or some of the Flow Sheets listed in Appendix F.

Q20. “Do you use some or all of the Flow Sheets listed in Appendix F?”


30% 70% Do you use all orsome of the Flow

Sheets?

Yes NoBase: n = 23


The majority of physician respondents (67%) think there are other types of Sample Chronic Disease Flow Sheets that should be included.

Q21. “In your view are there any other types of Sample Chronic Disease Flow Sheets that should be included?”


67% 33%

Are there any othertypes of Sample

Chronic Disease FlowSheets that should be

included?



Q21. “Comments.”

Comments regarding whether there are any other types of Sample Chronic Disease Flow Sheets that should be included were received from 6 physician respondents:

• Smoking • Physical inactivity • Chronic pain • Osteoarthritis • Frailty • Obesity • Diet • Insulin and dose adjustment • Laboratory results, investigative reports, specialist reports, and

prescriptions



• Counselling CBT • Anxiety • ADHD • Grief

The majority of physician respondents (87%) do not refer to Appendix G.

Q22. “Appendix G contains information regarding choosing an Electronic Medical Record (EMR) Vendor. Do you refer to this Appendix?”


13% 87% Do you refer toAppendix G?

Yes NoBase: n = 23

Figure 17: Appendix G

The majority of physician respondents (65%) don’t know if the information contained in Appendix G is helpful.

Q23. “In your view, is the information contained in Appendix G helpful?”


22% 13% 65% Is the information

contained in AppendixG helpful?



The majority of physician respondents (60%) don’t think there is other information that should be included in Appendix G.

Q24. “In your view, is there other information that should be included in Appendix G?”


60% 40%

Is there otherinformation that

should be included inAppendix G?



Part 2: Questions for All (*Except Organizations)

The following questions were posed to all respondents (except organizations) to obtain information about their experience as a user or patient of the health care system.

As they did not require respondents to have read the current policy, the questions in this section were posed to all respondents except for those who identified as an organization.


The majority of respondents (61%) have never asked their physician for a copy of their medical record.

Q25. “For the next set of questions, we'd like you to think about your experiences as a user or patient of the healthcare system. Have you ever asked your physician for a copy of your medical record?”


39% 61%

Have you ever askedyour physician for a

copy of your medicalrecord?

Yes NoBase: n = 38

Figure 20: Request for medical record

The majority of respondents (71%) requested a copy of their medical record for themselves.

71%

43%

14%

7%

For yourself

For another health care provider

For another complaint or legal proceeding

Other (please specify)

If yes, for what purpose?

Q26. “If yes, for what purpose?”

Base: n = 14

Figure 21: Reason for request


Q26. “Other (please specify).”

Comments regarding other reasons for requesting a copy of their medical record were received from 1 respondent:

• I feel as a patient, I am entitled to have a copy of all of my test results for my own records to be able to reference back to it.

• I also feel that patients should be entitled to have a copy of their records, and not have to pay for it either. After all, it is our healthcare and our body that is being taken care of, so why charge us?

This is representative of the comment received.


The majority of respondents (64%) said there was a fee for the summary or copy of the entire record.

14%

36%

29%

64%

A summary of the record was provided ina timely manner.

A copy of the entire record was providedin a timely manner.

A summary or copy of the entire recordwas not provided.

There was a fee for the summary or copyof the entire record.

Please review each of the following statements and select those that apply to your experience.

Q27. “Please review each of the following statements and select all that apply to your experience.”

Base: n = 14

Figure 22: Experience


Q28. “Did you experience any issues accessing a summary or copy of your entire medical record?”

Comments regarding issues accessing a summary or copy of their entire record were received from 9 respondents:

• No. • Yes, as clinic managers are charging too frequently. • The physician was leaving practice and gave me my medical records so I

could take them to my new physician. • I requested medical records from a specialist and never heard back. • They were difficult to understand because they were not typed; they were

inaccurate; and the fee was not reasonable. • I received a copy of a few reports from my former physician and was asked

for what time periods I wanted this for. They allowed me about 30 pages and charged me $50.



Q29. “Do you have any other comments about your experience?”

Other comments regarding their experience were received from 7 respondents:

• No. • EMR helplines are too busy. • I had the option (at a cost) of receiving paper and/or a CD for my new

physician. • Patients shouldn’t be charged for picking up a copy of their record and

bringing it to their new physician; the record belongs to the patient. • I live over 100 kms away but would have made the trip to pick up a copy of

my record and deliver it to my new physician. No information was ever sent.

• I had to repeatedly get in touch with my former physician to transfer my record to my new physician. My former doctor would not transfer the entire record and instead charged me for the transfer of certain reports.



Part 3: Questions for All

The following questions were posed to all respondents to obtain their views on various issues related to medical records and the current policy.

As they did not require respondents to have read the current policy, the questions in this section were posed to all respondents.


The majority of respondents (74%) think the College should set out expectations for physicians on recordings.

Q30. “Some patients may want to bring their smartphones to their appointments to record some or all of their clinical health care encounter. At times, physicians may also want to record some or all of the clinical health encounter for various purposes (e.g. patient care, education, research). The current policy does not address this issue. Do you think the College should set out expectations for physicians on recordings?”


74% 10% 16%

Do you think theCollege should set out

expectations forphysicians onrecordings?


Figure 23: Recordings

Q31. “Please explain.”

Comments regarding whether the College should set out expectations for physicians on recordings were received from 22 respondents:

• Patients should be allowed to record their visit as it is their choice and their healthcare.

• If physicians are going to record, the reason should be very specific and not just for “patient care or education” reasons; patient consent should be required.

• All encounters should be videotaped. • Recordings should not be allowed, as they eliminate a certain level of trust

between the physician and patient. • The current haphazard approach is not really acceptable for either patients

or physicians, and the legal aspects of these recordings are not clear. • If a recording would be considered part of the patient record, it must be

addressed as to how that can correctly take place. It will also need to be addressed by privacy legislation.



The majority of respondents agreed (either strongly or somewhat) that physicians should be able to decide whether they would like to retain records longer than the time period required in regulation (64%). Respondents were divided about whether physicians should be required to retain records for at least 15 years, and whether it is unreasonable for physicians to retain records for at least 15 years.

42%

39%

29%

22%

6%

9%

11%

14%

17%

8%

19%

14%

17%

22%

31%

Physicians should be able to decide whether they wouldlike to retain records for longer than the time period

required in regulation.

Physicians should be required to retain records for at least15 years.

It is unreasonable to expect physicians to retain records forat least 15 years.

Strongly agree Somewhat agree Neither agree nor disagree Somewhat disagree Strongly disagree

Q32. “Please indicate the extent to which you agree or disagree with each of the following statements regarding retention requirements.”

Base: n = 36

Figure 24: Retention requirements


The majority of respondents agreed (either strongly or somewhat) that it is in the physician’s best interest to retain records for at least 15 years (58%), and that it is in the patient’s best interest to retain records for at least 15 years (50%).

39%

39%

19%

11%

22%

19%

3%

17%

17%

14%

It is in the physician’s best interest to retain records for at least 15 years in the event of a legal proceeding.

It is in the patient’s best interest to retain records for at least 15 years.

Strongly agree Somewhat agree Neither agree nor disagree Somewhat diagree Strongly disagree

Q32. “Please indicate the extent to which you agree or disagree with each of the following statements regarding retention requirements.” (Continued)

Base: n = 36

Figure 24: Retention requirements


Respondents were divided about whether physicians should be required to retain records longer than the above mentioned retention requirements for certain types of patients.

Q33. “In your view, should physicians be required to retain records for longer than the above mentioned retention requirements for certain types of patients (e.g. those with congenital diseases, conceived using a sperm or egg donor, etc.)?

Page 41 – Maintaining Appropriate Boundaries and Preventing Sexual Abuse Online Survey Report – Dec 2017

39% 42% 19%

Should physicians berequired to retain recordsfor longer than the above

mentioned retentionrequirements for certain

types of patients?


Figure 25: Records retention

Q34. “If yes, please indicate in which circumstances records should be retained for longer than 15 years, the length of time you think they should be retained for.”

Comments regarding retaining records for longer than 15 years were received from 15 respondents:

• For those with congenital diseases and who were conceived using a sperm or egg donor.

• For obstetrical complications; for mental health issues; where it is a health issue that will affect the patient for the majority/entirety of their life.

• Variations in records retention across family practice and specialty care will be very complicated to administer and for physicians to navigate.

• Should be a central place where all records are kept. • Physician should maintain records indefinitely; could be stored in smaller

formats to accommodate. • If longer than 10 years, the costs should be borne by the provincial

government. • The patient should retain the record; best way would be to give the patient

a summary after each visit.



The majority of respondents disagreed (either strongly or somewhat) with the statement that physicians must maintain “skeletal” or temporary notes (66%), agreed (either strongly or somewhat) with the statement that physicians must use their clinical judgment to determine whether to retain them (75%), and disagreed with the statement that it is reasonable to require physicians to retain them (64%).

17%

47%

11%

11%

28%

19%

6%

8%

6%

11%

11%

19%

55%

6%

45%

Physicians must retain “skeletal” or temporary notes as part of the patient’s medical record.

Physicians must use their clinical judgment to determine whether “skeletal” or temporary notes are retained as part

of the patient’s medical record.

It is reasonable to require physicians to retain “skeletal” or temporary notes as part of the patient’s medical record.


Q35. “Please indicate the extent to which you agree or disagree with each of the following statements regarding “skeletal” or temporary notes.”

Base: n = 36

Figure 26: “Skeletal” or temporary notes


The majority of respondents agreed (either strongly or somewhat) with the statement that it is not necessary for physicians to retain “skeletal” or temporary notes (70%), and disagreed (either strongly or somewhat) with the statement that they must be included in the patient’s medical record… before a comprehensive note is formally entered (50%).

62%

25%

8%

14%

8%

11%

14%

11%

8%

39%

It is not necessary for physicians to retain “skeletal” or temporary notes as part of the patient’s medical record

once they have been used to make the formal entry in the record.

“Skeletal” or temporary notes must be included in the patient’s medical record so there is some basic information about the clinical encounter before a comprehensive note

is formally entered by the physician.


Q35. “Please indicate the extent to which you agree or disagree with each of the following statements regarding “skeletal” or temporary notes.” (Continued)

Base: n = 36

Figure 26: “Skeletal” or temporary notes



Comments regarding “skeletal” or temporary notes were received from 17 respondents:

• They are an aide memoire and could be easily misconstrued if taken out of context.

• Skeletal notes may conflict with the formal entry if additional information is obtained or research is conducted after writing the skeletal note.

• Often messy and only understandable to the physician; would result in cluttered/disorganized record.

• No need for temporary notes if notes are entered at time of visit/after the visit; should be destroyed after formal entry made.

• Should be at the discretion of the physician whether they are retained. • Could be helpful if the physician’s EMR is down. • All information should be included in the formal record; physicians could

have missed something.



The majority of respondents (53%) thought the next iteration of the policy should address clinical notes that are “dictated but not read”.

Q37. “Do you think the next iteration of the policy should address dictated clinical notes that are saved in the medical records without the physician having reviewed them (e.g. notes that are “dictated but not read”)?


53% 28% 19%

Do you think the nextiteration of the policyshould address clinical

notes that are"dictated but not

read"?


Figure 27: “Dictated but not read”


Comments regarding clinical notes that are “dictated but not read” were received from 14 respondents:

• Dictated notes often contain errors. • There have been lots of errors in records; often trainees are the authors. • All notes need to be reviewed, and any errors must be corrected, in a

timely fashion (within 24 hours). • Physicians should be accountable for ensuring the note is accurate and

complete. • “Dictated but not read” is neither an excuse or an alibi. • There is nothing wrong with the current policy. • The College is already too intrusive.



The majority of respondents agreed (either strongly or somewhat) with the statement that templates/checklists are helpful tools (88%), disagreed (either strongly or somewhat) with the statement that it is appropriate to only use templates/checklists (52%), and disagreed with the statement that physicians must not use pre-populated templates (56%).

63%

19%

25%

25%

20%

8%

6%

20%

11%

6%

19%

22%

33%

34%

Templates/checklists are helpful tools physicians can usewhen documenting clinical encounters.

It is appropriate to only use templates/checklists todocument clinical encounters.

Physicians must not use pre-populated templates whendocumenting clinical encounters.


Q39. “Please indicate the extent to which you agree or disagree with each of the following statements regarding clinical notes and the use of templates and checklists.”

Base: n = 36

Figure 28: Templates/checklists


The majority of respondents agreed (either strongly or somewhat) with the following statements: that physicians must use templates/checklists that allow entry of free-text (67%), that physicians must use templates that can be customized (73%), and that physicians must verify that the information… is accurate and comprehensive (92%).

47%

53%

78%

20%

20%

14%

19%

8%

5%

6%

11%

8%

8%

Physicians must use templates that allow entry of free-text.

Physicians must use templates that can be customized toinclude relevant descriptive details.

Physicians must verify that the information contained inthe templates/checklists they use is accurate and

comprehensive.


Q39. “Please indicate the extent to which you agree or disagree with each of the following statements regarding clinical notes and the use of templates and checklists.” (Continued)

Base: n = 36

Figure 28: Templates/checklists



Comments regarding templates/checklists were received from 11 respondents:

• It should be the physician’s choice as to whether or not they use templates/checklists.

• Physicians shouldn’t solely rely on templates. • There is too much variation in patient needs; templates/checklist shouldn’t

be used. • Dependence on a checklist could lead the physician to overlook or fail to

remember something relevant. • Templates could reduce the amount of time it takes to document the

encounter, leaving more time to spend with patients. • Templates/checklists provide cognitive reminders to clinicians during the

encounter. • The College should consider patient safety evidence re: checklists.



The majority of respondents (56%) thought the expectation set out in the current policy regarding Optical Character Recognition (OCR) is reasonable.

Q41. “In your view, is the expectation set out in the current policy regarding Optical Character Recognition (OCR) reasonable?”


56% 14% 30%

Do you think theexpecation set out inthe current policy re:OCR is reasonable?


Figure 29: Optical Character Recognition (OCR)


Comments regarding the expectation set out in the current policy regarding Optical Character Recognition (OCR) were received from 8 respondents:

• Originals are originals and should be stored as such. • It is reasonable because if there is any change made to a medical record,

the original should be kept as mistakes can easily be made. • OCR technology is not perfect and should not be relied upon. • Voice recognition is notoriously unreliable. • A review of the current technology needs to be undertaken. • I would assume that physicians would be accountable for the converted

document. • The capacity to retain to much paper is limited; physicians shouldn’t have

to retain.



Familiarity with the Current Policy

The majority of respondents (82%) indicated that they had read the current policy (see Table 4).

Have you read the Medical Records policy?

n = 33

Yes 27

82%

No 6

18%

Table 4: Read policy

Respondents who indicated that they had not read the current policy were given the opportunity to do so before proceeding, or skip to the questions at the end of the survey (regarding consultation experience).


Part 4: General Questions

The following questions assess respondents’ opinions of the current policy.

As such, the questions in this section were only posed to those respondents who indicated that they had read the current policy.


The majority of respondents (52%) thought it is necessary to provide specific medical record-keeping requirements for the types of encounters included in Appendix D.

Q44. “Is it necessary to provide specific medical record-keeping requirements for the types of encounters included in Appendix D?”


52% 37% 11%

Do you think it isnecessary to provide

specific medical record-keeping requirements forthe types of encountersincluded in Appendix D?


Figure 30: Appendix D


Comments regarding the specific medical record-keeping requirements for the types of encounters included in Appendix D were received from 10 respondents:

• Charting requirements for these encounters are all very different and physicians need guidance.

• These visits have more risk. • To help the physician and for legal reasons. • Only for OHIP billing reasons. • It may cover more than the actual scope of the encounter. • Differences could be addressed through the use of templates. • “Objective” information should be clearly specified to include both physical

examinations and mental status examinations.



The majority of respondents (41%) didn’t know if there are other types of encounters where specific medical record-keeping requirements are necessary.

Q46. “In your view, are there other types of encounters where specific medical record-keeping requirements are necessary?”


26% 33% 41%

Are there other types ofencounters where specific

medical record-keepingrequirements are

necessary?


Figure 31: Appendix D

Q47. “If yes, please specify the type of encounter(s).”

Comments regarding the types of encounters where specific medical record-keeping requirements are necessary were received from 8 respondents:

• Most clinical settings. • Medical assistance in dying. • Telephone. • Family meetings. • Minor procedures done in the office. • Operative notes. • Patients should be able to say whether they want the details of something

written in their medical record (e.g. if they want the physician to write “physician-patient confidentiality” instead of detailing what happened, so no one else can read the specifics).



Part 5: Clarity and Comprehensiveness

The following questions assess respondents’ general opinions of the clarity and comprehensiveness of the current policy.

As such, the questions in this section were only posed to those respondents who indicated that they had read the current policy.


Overall, the majority of respondents agreed (either strongly or somewhat) that the draft policy clearly articulated physicians’ professional obligations (63%), was easy to understand (56%), clearly written (74%), and well organized (63%).

22%

19%

22%

19%

41%

37%

52%

44%

15%

11%

11%

19%

18%

26%

4%

11%

4%

7%

11%

7%

The policy clearly sets out physicians'professional obligations

The policy is easy to understand

The policy is clearly written

The policy is well organized


Figure 32: Clarity

Base: n = 27

Q48. “Please indicate the extent to which you agree or disagree with each of the following statements regarding the clarity of the policy.”


10 respondents provided feedback with respect to how the clarity of the policy could be improved:

• Very long and wordy. • There is a lot of content and it addresses both paper and electronic records.

This adds complexity. • Greater clarity for multidisciplinary clinics; for patients regarding what the

record-keeping requirements are. • Clarify when patients are considered a patient (e.g. if they have seen the

physician within the last 2 years?). • Be clear about what is mandatory vs. recommended. • Explain why special record-keeping is necessary for many conditions. • Remove the distinction between family/procedural medicine roles as some

family physicians may do procedures. • Patients shouldn’t have to pay for a copy of their medical record.


Q49. “In what ways can we can improve the policy’s clarity?”


While most respondents agreed (either strongly or somewhat) that the current policy was comprehensive (67%), some felt that it had failed to address at least one relevant or important issue (22%).

30% 37% 11% 15% 7% The policy is

comprehensive.


Q50. “We’d like to understand whether the current policy is comprehensive. That is, it addresses all of the relevant or important issues related to medical records. Please indicate whether you agree or disagree that the policy is comprehensive.”

Base: n = 27

Figure 33: Comprehensiveness


14 respondents provided suggestions for additional items that could be included in the next iteration of the policy:

• Address privacy breaches, multidisciplinary clinic records, long-term care records, mental status examinations, “skeletal” or temporary notes, patient recording of clinical encounters, how many copies of the record must be retained, and who assumes control of the records after a physician dies.

• Include detailed requirements re: security of information and psychotherapy.

• Revisit the increased use of digital health records. • Require that all medical records be typed. • Hospital privileges should be suspended if hospital charts are not

completed within 2 weeks. • The College can’t provide specific expectations for every type of clinical

practice; general policy is sufficient.


Q51. “Are there any specific issues regarding medical records that we don’t cover in the current policy, but should in next iteration of the policy?”


7 respondents provided additional comments:

• Clarify who is responsible for investigation follow-up and to the patient when they are awaiting a specialist appointment.

• Email communication should be encouraged; patients shouldn’t need an appointment for straightforward information.

• It is unreasonable to retain records for 10 years after the child turns 18; 1 year would be sufficient.

• Outline what the consequences are when destroying records after the retention period.

• College should appraise physicians each year and revalidate physicians every 5 years like in the UK. Would give physicians a chance to hear from assessors and improve their practices.

• Current peer review process is stressful for physicians; assessors should assess records and not police the practice of medicine (don’t need to always find something wrong).


Q52. “If you have any additional comments that you have not yet had the opportunity to share, please feel free to provide them below, by email or through our online discussion forum.”


medical records: online survey...

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