But how does one effectively maintain records and ensure that they serve their ultimate purpose (being to benefit the patient)? How does keeping good records become an instinct rather than a chore?
General Practitioner Weekly provides five tips for keeping good medical records:
- Ensure notes include enough information to identify the patient
- Write notes in a timely manner
- Protect records from accidental disclosure
- Ensure your notes are accurate, legible, and contain enough information
- Never alter the records
The bottom line is that keeping medical records must be accessible in a way that ensures continuity and quality of care.
CPD goes even deeper with a one-day workshop designed to equip participants with the tools needed to maintain medical records that truly fulfill their purpose.
The goal of the workshop is to help physicians comply with the CPSO Medical Records Policy, so following the rules becomes easy and natural rather than time-consuming and overwhelming.
One participant from the September 2015 workshop said that following the day spent discussing effective techniques, they felt more confident about day-to-day note-taking.
“It’s very, very helpful to know how to structure the consultation with templates,” they said, noting that their counselling and consultant’s reports had improved.
The next Medical Record Keeping workshop will be held on September 22, 2016. For more information or to register online, visit www.cpd.utoronto.ca/recordkeeping.