Documentation in clinical notes and reports to third parties should be factual, objective, and use a suitable tone of medical professionalism.
Information on consent and access to records when child protective services are involved.
Practising physicians, particularly those at the beginning of their career, should ensure they have enduring access to medical records after leaving a practice for medical-legal purposes.
Responsibilities of physicians when planning to close or leave a practice due to retirement, illness, or other reasons.
Physicians may face a privacy breach when viewing personal health information that is not required for current clinical care and without the patient’s or information custodian’s consent.
An overview of changes to federal and provincial privacy laws.
Answers to questions physicians have been asking about the use of AI scribe services
When physicians wish to record a clinical encounter, they should first obtain express consent from the patient and have in place security measures to ensure confidentiality.
Physicians may release a patient’s medical records to lawyers only with patient authorization or where required by law.
Advice for physicians travelling across international borders and carrying devices that may contain patient information.
The physician's role in providing a child's medical information to a parent.
Individuals have a general right to access their personal information in independent medical examination files, but there are exceptions to what must be produced
Addressing privacy breaches has become more complex as the rules around notifying and reporting have recently changed or are about to change across the country.
Physicians can be better prepared to transfer patient health information when they understand who has custody of and access to medical records.
Considerations for physicians when responding to requests for deceased patients’ medical records.
A discussion of the principles of access, the challenges with access, and managing the risks.
An overview of the principles of retention, sharing and transferring of medical records.
How doctors can help protect their information technology systems from cybersecurity threats and what they should do in the event of a cybersecurity incident.
Physicians should try to accommodate patients’ requests to limit access to their personal health information.
The practice of marking transcribed reports or entries “dictated but not read” gives rise to medical-legal risks and can create uncertainty for those relying on that information in providing patient care.
Actions physicians can take to mitigate potential risks of using patient portals to communicate clinical information with patents.
Strategies for managing the stress associated with transitioning to a new EMR system for managing patient records.
DISCLAIMER: This content is for general informational purposes and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. Your use of CMPA learning resources is subject to the foregoing as well as CMPA's Terms of Use.
