According to the College of Physicians and Surgeons of Ontario (CPSO), physicians have the duty to document all encounters related to the clinical care of the patient using any form of communication whether is in-person or virtual. It has to be complete and has to " tell the story". Even after the patient being discharge , the doctor has to keep all records for 10 years.
"The physicians must provide patients and authorized parties with access to, or copies of, all the medical records in their custody or control upon request, unless an exception applies.
Where an exception applies and access is refused, physicians must inform the individual in writing of the following:
the fact of the refusal;
the reason for the refusal; and
the right of the patient to make a complaint to the Information and Privacy Commissioner of Ontario (IPC).
Physicians must provide patients and authorized parties with explanations of any term, code, or abbreviation used in the medical record, upon request.
Fees for Copies and Transfer of Medical Records
Fulfilling a request for copying and transferring medical records is an uninsured service. As such, physicians are entitled to charge patients or third parties a fee for obtaining a copy or summary of their medical record."
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