Patient Record Content

About the standard

The Patient Record Content standard was last updated in 2016 and is being reviewed to ensure it accurately reflects current medical practices. A proposed expansion of required documentation regarding timing, declined treatment and history improves patient safety, continuity of care and information sharing for other providers. The addition of EMRs, templates and virtual care guidance aligns with current clinical workflows to support modern systems and evolving technologies. Finally, the inclusion of medical scribes and AI provides clarification and direction in managing patient privacy and data security.

What’s changed?

• Amendments strengthen clinical rationale, informed decision-making and ensure availability of information involved in litigation or complaints.
• Addition of EMRs, templates and virtual care better align with current clinical workflows, support modern systems and minimize potential documentation challenges.
• Inclusion of medical scribes and AI provides clarification on following privacy legislation and professional standards to protect patient privacy and data security.
• Expanded documentation requirements concerning date of encounter, declined treatments/tests, detailed history and assessment support patient safety, and improves continuity of care and data sharing.