6Standards for adequate and contemporaneous records

6 Standards for adequate and contemporaneous records

For the purposes of the definition of adequate and contemporaneous records in subsection 81(1) of the Act, the standards for a record of the rendering or initiation of services to a patient by a practitioner are that: (a) the record must include the name of the patient; and (b) the record must contain a separate entry for each attendance by the patient for a service; and (c) each separate entry for a service must: (i) include the date on which the service was rendered or initiated; and (ii) provide sufficient clinical information to explain the service; and (iii) be completed at the time, or as soon as practicable after, the service was rendered or initiated; and (d) the record must be sufficiently comprehensible to enable another practitioner to effectively undertake the patient’s ongoing care in reliance on the record.