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.
View the draft standard
For your convenience, the draft standard has clean and marked copies available.
All ResourcesYour opinion matters
Changes to CPSA’s Standards of Practice impact your day-to-day practice. Your feedback is important to us, as it helps us develop clear, reasonable expectations and helpful, applicable resources. We appreciate the time you took and the input you provided.
CPSA regulated members, partner organizations, other healthcare professionals and Albertans were invited to provide feedback from Jan. 6 to Feb. 5.
Anonymized feedback will be considered by Council. Once amendments are finalized and approved by Council, members will be notified by email and The Messenger newsletter.
We respect your privacy
All feedback is subject to CPSA’s Privacy Statement. CPSA reviews all comments before publication to ensure there is no offensive language, personal attacks or unsubstantiated allegations.
Other feedback on this standard
Does a parallel universe exist somewhere, in which Standards of Practice get shorter over time? 🙂 It's a joke, but...
I've torn up 3 drafts of feedback on this Standard, and have now given up. The issues involved are structural and systemic, and re-wording simply doesn't get at the root problems. The paradigm reflects a paper chart, managed by a single provider - which no longer matches reality, particularly with Connect Care (i.e. a provincial-level shared chart) or other EMRs used by multiple people.
Sooner or later, the CPSA needs to tackle documentation burden. There are reasons why AI scribes, and templated notes, are exploding. There's something wrong when docs are spending hours “after work” charting, and >90% of that writing will never be read, by anyone, ever. One problem is that docs are incentivized (by the CPSA, and lawyers) to "completely and comprehensively" record what they did and why they did it - but there are no incentives (including in this draft Standard of Practice) to contribute to the record in a way that really helps patient care. As one simple example,
Dr A: "Have you ever tried [an antidepressant/BP med/diabetes med/etc]?"
Mr. B: "I think so, sounds familiar."
Dr A: "Any idea what happened? Did it work? Do you know why you stopped it?"
Mr. B: "I'm sorry, I just don't remember. Don't you have that in the computer?"
Dr A: "I wish..."
We're mandated to have a list of current medications (which remains important, and has significant limitations), but wouldn't it be great if something as basic to medical care as "past treatments tried, and what happened" was in the chart, without having to sift through scores of individual visit notes looking for clues? As just one example?
While i completely understand and support the need for quality notes and records ,the introduction of ConnectCare has in my experience introduced new perils.
The suggestion of expansion of documentation and smarttexts for improved quality will introduce note bloat making notes so long and cumbersome unlikely to be read by both author and others increasing risk of errors.
Few now actually read all of their notes as most was smart texted in. The long-pasted note also leads to perpetuation of errors .i have encountered errors in gender where one person was referred to in same admission as he and then she and third author to save time uses they for everyone in their smattexts format notes hey .the same issue the same has occurred with right and left. Expanded longest notes most of which is pasted from others and seldom read carries many risks to author