Patient Record Content

Standard of Practice

Under Review: No
Issued by Council (Patient Records): January 1, 2010
Reissued by Council: July 1, 2011
Reissued by Council (Patient Record Content): January, 2016
Reissue included both Patient Record Content and Patient Record Retention.

The Patient Records standard was split into Patient Record Content and Patient Record Retention in January 2016. Please refer to both standards for all expectations related to patient records.

  1. A regulated member who provides assessment, advice and/or treatment to a patient must:
    1. document the encounter in a patient record (paper or electronic);
    2. ensure the patient record is:
      1. an accurate and complete reflection of the patient encounter to facilitate continuity in patient care;
      2. legible and in English;
      3. compliant with relevant legislation and institutional expectations; and
      4. completed as soon as reasonable to promote accuracy.
  2. A regulated member must ensure the patient record contains:
    1. clinical notes for each patient encounter including:
      1. presenting concern, relevant findings, assessment and plan, including follow-up when indicated;
      2. prescriptions issued, including drug name, dose, quantity prescribed, directions for use and refills issued;
      3. tests, referrals and consultations requisitioned, including those accepted and declined by the patient; and
      4. interactions with other databases such as the Alberta Electronic Health Record (Netcare).
    2. Information pertaining to the consent process;
    3. a cumulative patient profile (CPP) contextual to the physician-patient relationship (the longer and more complex the relationship the more extensive should be the record) detailing:
      1. patient identification (i.e., name, address, phone number, personal health number, contact person in case of emergencies);
      2. current medications and treatments, including complementary and alternative therapies;
      3. allergies and drug reactions;
      4. ongoing health conditions and identified risk factors;
      5. medical history, including family medical history;
      6. social history (e.g., occupation, life events, habits);
      7. health maintenance plans (immunizations, disease surveillance, screening tests); and
      8. date the CPP was last updated;
    4. laboratory, imaging, pathology and consultation reports;
    5. operative records, procedural records and discharge summaries;
    6. any communication with the patient concerning the patient’s medical care, including unplanned face-to-face contacts;
    7. a six-year history of patient billing encounter data as required by Alberta Health (identifying type of service, date of service and fee(s) charged); and
    8. a record of missed and/or cancelled appointments.
  3. Notwithstanding clause (2) a regulated member may indicate that the required documents are available in Netcare or other database that can be reliably accessed for the length of time the record must be maintained.
  4. A regulated member may amend or correct a patient record in accordance with the Health Information Act (HIA) through an initialed and dated addendum or tracked change including the following circumstances:
    1. the correction or amendment is routine in nature, such as a change in name or contact information;
    2. to ensure the accuracy of the information documented; or
    3. at the request of a patient identifying incomplete or inaccurate information.
  5. Notwithstanding (4c), a regulated member may refuse to make a requested correction or amendment to a patient record in accordance with the HIA.
  6. A regulated member may append additional information to a patient record in accordance with the HIA.

About the Standards of Practice

The CPSA Standards of Practice are the minimum standards of professional behaviour and ethical conduct expected of all physicians registered in Alberta. Standards of practice are enforceable under the Health Professions Act and will be referenced in the management of complaints and in discipline hearings.


For questions or archived standards, policies and guidelines contact our Standards of Practice Coordinator.

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