Consultation 32

About the consultation

Patient Record Content

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.

Patient Record Retention

The Patient Record Retention standard was last updated in 2016 and is being reviewed to ensure relevancy to current medical practices. A proposed title change to Patient Record Management better reflects the content covered within the standard. Guidance added regarding access, locum responsibilities and preventing abandoned records clarifies responsibilities of custodians and strengthens continuity of care. In accordance with the Health Information Act, EMR system requirements have been added to modernize and support current practices. Additional details regarding record storage, security and access requirements help support patients and transparency.