Are you up to standard? Patient Record Content

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As Alberta’s medical regulator, CPSA relies on feedback and first-hand experiences from our regulated members and Albertans to gain an understanding of concerns, observations or questions related to health care. Recently, we heard from a regulated member regarding an article we shared in February’s Messenger—”Seeing patients after treatment abroad: a clinical experience and lessons learned”—as well as the Patient Record Content standard of practice.

CPSA’s Deputy Registrar, Dr. Susan Ulan, had an insightful exchange with a regulated member who voiced concerns over CPSA’s expectations regarding documentation, suggesting we share a refresher on CPSA’s Patient Record Content standard.

The Patient Record Content standard was created to standardize procedures for keeping patients’ medical records. Some key requirements of the standard include:

• All patient encounters need to be thoroughly documented in the patient record as soon as possible, to ensure accuracy while providing care.
• Encounter notes should be as thorough as possible and include presenting concerns, relevant findings, assessment plans and follow-up, prescriptions issued, tests, referrals and consultations requisitioned, and interactions with other databases.
• The patient record should be a cumulative profile containing patient identification, current medications and treatments, allergies and drug reactions, ongoing health conditions and identified risk factors, as well as a medical and social history.

CPSA recognizes regulated members don’t always have enough time to record every single detail, but even short and concise notes can make a difference in continuity of care and in the event a question or concern arises. For example, if you’re prescribing a new medication for a patient, it may not be realistic to list every possible adverse reaction. However, if you provide your patient with additional resources or places to find more information on potential reactions, you can note the information you provided.

For information on maintaining patient records, please read the Patient Record Retention standard of practice.

CPSA welcomes and appreciates feedback from regulated members and Albertans. If you have any ideas on how we can better support you, please feel free to reach out.

Questions? Contact CPSA’s Standards of Practice Advisor at chantelle.dick@cpsa.ab.ca.