1.4.2 What is a patient record?

Since a patient may have been admitted several times during the period in which our data were
collected, it is important to understand exactly how to identify patients and his/her stay(s).
There are essentially four identifiers for data associated with any given patient:
Subect !" (Subject_ID) # an integer number identifying a particular patient. This can be
thought of as a substitute for a uni$ue medical record number. !n the flat file data posted
on %hysio&et, the number representing the Subect'!" is left padded with (eros to five
digits and preceded by the letter s. !n the relational database, the Subect'!" has no
preceding letter or leading (eros.
)ospital admission !" (Hadm_ID) # an integer number identifying a particular admission
to the hospital. *ach patient may have many Hadm_IDs associated with his/her uni$ue
Subject_ID.
!+, stay !" (ICUstay_ID) # an integer number identifying an !+, stay. -n !+, stay,
refers to the period of time when the patient is cared for continuosly in an !ntensive +are
,nit. *ach patient may have one or more !+, stays associated. -n !+, stay is
considered to be continuous if any set of !+, events (such as bed transfers or changes in
type of service) belonging to one Subect'!" which are fewer than ./ hours apart.
0onger brea1s in the patient2s stay automatically cause a new ICUstay_ID to be assigned.
+ase !" (Case_ID) # This is a five digit number preceded by the letter a (for adults) or n
(for neonates). This !" indicates a set of waveforms associated with a given patient. 3or
various reasons (described in section: 4./.5 below), there may be multiple case !"s
associated with a given patient.
3igure 4./ illustrates the possible data available for a given individual, identified by a
66subect'id22. Time progresses from left to right, and the different types of data collected are
shown vertically. *ach subect can have multiple hospital admissions, identified with
66hadm'ids22. *ach hosptial admission can contain multiple !+, stays, identified with
66icustay'ids22. 7aveforms collected during !+, stays are identified using 66case'ids22.
0aboratory and microbiology tests are performed throughout a hospital stay and can therefore
ta1e place outside the !+, stay. 8ital sign validation, medications, fluid balances and nursing
notes are only performed in the !+, and are not available during the remainder of the hospital
stay. "ate of death is recorded in#hospital and has also been obtained from social security records
for out#of#hospital mortality.
The above illustrates an 66ideal22 case where the timestamps associated with the data fall within
the hospital and/or !+, stay. ,nfortunately, real#world issues can complicate matters allowing
data to be recorded outside of a patient stay. 3or example, a patient could be physically present in
the !+, and connected to monitors before their admission has been entered into the system. This
results in a waveform recording which starts before the subect2s !+, admission. 3urthermore,
missing/mista1en data can mean that !+, stays exist where there is no matching hospital
admission record.
Figure 1.4: Schematic of a patient record. &ote that the patient may experience several hospital
admissions and !+, stays, for which differing amounts of data are available. See section 4./.. for
details.
Types of Medical Records
NOTE: 8eterans who plan to file a claim for medical benefits with the "epartment of 8eterans
-ffairs (8-) do not need to re$uest a copy of their military health record from the &%9+. -fter a
claim is filed, the 8- will obtain the original health record from the &%9+. !n addition, many
health records were lent to the "epartment of 8eterans -ffairs prior to the 4:;5 3ire. 8eterans
who filed a medical claim should contact the "epartment of 8eterans -ffairs (8-) in order to
determine if their record is already on file. The 8- Toll 3ree < is: 4#=>>#=.;#4>>> # it will
connect the caller to the nearest 8- office.
Be specific as to what is wanted (asking for all medical records, just gets Health record, N!
In"#atient $ecord%:
The ?fficial @ilitary %ersonnel 3iles (?@%3), held at the &ational %ersonnel 9ecords +enter
(&%9+), are administrative records containing information about the subect2s military service
history. @any ?@%3s (but not all) contain both personnel and former active duty health records,
but the service branches discontinued retiring the health record portion to the &%9+ in the
4::>s.
Medical Record Type Description
HEALTH RECORD / SERVICE MEDICAL
RECORD / SERVICE TREATMENT
RECORD
All mean the same thing physicals and
!tpatient medical in"#matin
DENTAL RECORD R!tine Dental e$ams% &llings% dental '#(% etc)
IN*+ATIENT RECORD
9emained overnight in a hospital
Must specify hospital nae! "ocation! #ates or
appro$iate onth%year of treatent.
MENTAL HEALTH RECORD Mst ,ete#ans/#eti#ees d NOT ha,e s!ch a #ec#d
&ealth records cover the outpatient, dental and ental health treatment that former members
received while in military service. )ealth records include induction and separation physical
examinations, as well as routine medical care (doctor/dental visits, lab tests, etc.) when the
patient was not admitted to a hospital.
!n comparison, clinical 'hospital inpatient( records were generated when active duty members
were actually hospitali(ed while in the service. Typically, these records are &?T filed with the
health records but are generally retired to the &%9+ by the facility which created them (see
clinical records for more information). @edical records from the "epartment of 8eterans -ffairs
(8-) are also not included.
Aac1 to &%9+ 8eterans Service ?fficer (8S?) !nformation %age
)ntroduction
The medical record is a powerful tool that allows the treating physician to trac1 the patientBs
medical history and identify problems or patterns that may help determine the course of health
care.
The primary purpose of the medical record is to enable physicians to provide $uality health care
to their patients. !t is a living document that tells the story of the patient and facilitates each
encounter they have with health professionals involved in their care.
!n addition to telling the patientBs story, complete and accurate medical records will meet all
legal, regulatory and auditing re$uirements. @ost importantly, however, they will contribute to
comprehensive and high $uality care for patients by optimi(ing the use of resources, improving
efficiency and coordination in team#based and interprofessional settings, and facilitating
research. This is achieved in the following ways:
Quality of care: Medical #ec#ds cnt#i-!te t cnsistency and .!ality in
patient ca#e -y p#,iding a detailed desc#iptin " patients/ health stat!s and
a #atinale "# t#eatment decisins)
Continuity of care0 Medical #ec#ds may -e !sed -y se,e#al health
p#actitine#s) The #ec#d is nt 1!st a pe#snal mem#y aid "# the indi,id!al
physician 'h c#eates it) It all's the# health ca#e p#,ide#s t access
.!ic(ly and !nde#stand the patient/s past and c!##ent health stat!s)
Assessment of care: Medical #ec#ds a#e "!ndamental cmpnents "0
o e$te#nal #e,ie's% s!ch as thse cnd!cted "# .!ality imp#,ement
p!#pses 2e)g)% the Cllege/s +ee# Assessment +#g#am and
Independent Health 3acilities +#g#am4%
o in,estigatins 2s!ch as in.!i#ies made -y the C#ne#/s O5ce% and
Cllege in,estigatins4%
o -illing #e,ie's 2#ec#ds m!st -e p#pe#ly maintained in #de# "#
physicians t -ill OHI+ "# se#,ices4%
6
and
o physician sel"*assessments% 'he#e-y physicians #e7ect n and assess
the ca#e they ha,e p#,ided t patients 2"# instance% th#!gh patte#ns
" ca#e #ec#ded in the EMR4)
Evidence of care: Medical #ec#ds a#e legal dc!ments and may p#,ide
signi&cant e,idence in #eg!lat#y% ci,il% c#iminal% # administ#ati,e matte#s
'hen the patient ca#e p#,ided -y a physician is .!estined) The legal
#e.!i#ements "# medical #ec#ds a#e set !t in the Onta#i Reg!latins made
!nde# the Medicine Act, 1991 2#e"e##ed t in this plicy as the 8Reg!latin9
and attached at Appendi$ A4) Othe# legislatin that has an impact n medical
#ec#ds is listed !nde# 8Legislati,e Re"e#ences9 at the -eginning " this plicy)
This policy explains how medical records must be 1ept, outlining general re$uirements and
considerations about the collection, use, storage, and disclosure of patientsB personal health
information, with respect to both paper and electronic records. !t outlines re$uirements with
regard to access and retention periods to ensure continuity of care for patients. The policy
concludes by listing re$uirements for the contents of medical records, explaining what must be
included in records and how it must be documented.
%hysicians are ultimately responsible for meeting the expectations set out in this policy and may
assess their own medical record#1eeping practices by answering the $uestions listed in -ppendix
+, which have been ta1en directly from a protocol used in the +ollegeBs peer assessment
activities.
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*cope
This policy establishes principles and re$uirements for all medical records and applies to all
physicians. The policy indicates any additional re$uirements that exist based on the type of
record (e.g., paper, electronic or hospital#based records) or the physicianBs practice (e.g., primary
care, procedural medicine, group practice).
+urpose
The purpose of this policy is to set out physiciansB professional and legal obligations with regard
to medical records and to provide all practising physicians with a tool that will assist them in
implementing record#1eeping practices that are practical and easy to maintain.
+rinciples
!n accordance with The %ractice Cuide, the professional expectations in this policy are based on
the following principles:
:d medical #ec#d*(eeping is pa#t " p#,iding the -est .!ality medical
ca#e)
Acc!#ate and cmplete dc!mentatin in the medical #ec#d that is in
(eeping 'ith the #e.!i#ements " this plicy is essential in "acilitating and
enhancing cmm!nicatin in clla-#ati,e patient ca#e mdels)
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+olicy
The +ollege expects all physicians to 1eep medical records that are consistent with their legal
obligations and the expectations set out in this policy. 7hile many of the elements of the
guidance set out below are mandatory, other components of the policy are offered as
recommendations as to the best means of providing patients with $uality medical care. Those
elements of the policy that are mandatory will be explicitly indicated through the use of terms
such as DmustE, Dre$uiredE, or DexpectedE, whereas recommendations and advice will be
indicated through terms such as DshouldE, DrecommendedE, or DadvisedE.
1. O,er,ie- and [Link] of Medical /ecords
Legibility
The 9egulation re$uires that medical records be legible.
.
This can be accomplished through
legible handwriting, typed entries, voice dictation and transcription, electronic medical records,
or handwriting recognition software.
5
The +ollege expects that information in a medical record can be understood by other health
professionals. ,sing conventional medical short forms is permissible. )owever, to reduce error,
the meaning should be clear to a health professional reading the record. %hysicians should not
use abbreviations that are 1nown to have more than one meaning in a clinical setting.
7hile exceptions exist, patients may obtain access to the information in their medical records.
-lthough the medical record is not written primarily for the patient, physicians must be prepared
to provide explanations to patients of any term, code, or abbreviation used in the medical record.

/
Documentation of the atient Encounter
*very patient encounter and all patient#related information must be documented in either *nglish
or 3rench and dated in the medical record. 7here there will be more than one health professional
ma1ing entries in a record, each professionalBs entry must be identifiable, which may, in an
*@9, be accomplished through an audit trail. 7here a physician has limited control over the
content of a shared record, he or she is only accountable for his or her own entries into the
record.
The physician must ensure the accuracy of the entries made into the medical record on his or her
behalf by a trainee or the recipient of delegation. This may be indicated by cosigning the entry.
The Health Insurance &ct
F
re$uires that physicians record the start and stop time for certain
types of patient encounters, such as psychotherapy and counselling.
G
!n addition to these,
physicians should ensure that the start and stop times are recorded for some other types of
clinical encounters, such as resuscitation, administration of medications, and telephone
conversations.
The +ollege recommends that entries be recorded as soon as possible after the encounter. This is
important to ensure safe delivery of care, especially in coordinated care environments.
Chronological and !ystematic
!n office based practices where there is a single patient chart, it is expected that all materials in
each patient chart be ordered in a chronological and systematic manner. !n settings such as wal1#
in clinics, single patient files must be created and all documentation for a single patient must be
1ept in that patientBs file. !t is not appropriate to file by date.
Collection" #se" and Disclosure of $nformation
%hysicians must always obtain the patientBs consent when collecting, using or disclosing personal
health information (%)!), unless provided otherwise by law.
;
@andatory reporting re$uirements are an example of situations in which the disclosure of %)! is
re$uired by law.
=
+ircumstances in which physicians are permitted to collect, use, and/or disclose
%)! are set out in the 'ersonal Health Information 'rotection &ct, ())* ('HI'&%+
:
!f the collection, use, or disclosure is neither permitted nor re$uired by law and therefore patient
consent must be obtained, physicians should note that as members of what is commonly referred
to as the Dcircle of care,E 'HI'& allows them to assume a patientBs implied consent under
particular circumstances. - physician may only assume the implied consent of the patient to
collect, use, or disclose the patientBs %)! if:
they ha,e #ecei,ed the +HI "#m the patient% thei# s!-stit!te decisin ma(e#%
# anthe# health in"#matin c!stdian 2HIC4 "# the p!#pse " p#,iding #
assisting in the p#,isin " health ca#e t the patient%
the physician is !sing% cllecting% # disclsing
6;
the +HI "# the p!#pse "
p#,iding # assisting in the p#,isin " health ca#e t the patient% and
the patient has nt e$p#essly 'ithheld # 'ithd#a'n cnsent t the +HI -eing
cllected% !sed% # disclsed)
Commercial !ervices
%hysicians may wish to engage commercial providers for services such as storage, maintenance,
scanning, destruction, and other issues related to medical records. %hysicians should use due
diligence when selecting and engaging service providers. !t is strongly recommended that any
agreements with such providers be made in writing.
44
These agreements must reflect the same
legal and regulatory re$uirements that apply to physicians as health information custodians.
%hysicians are encouraged to see1 legal counsel or contact the +@%- for advice in these
circumstances.
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2. *ecurity and *torage
%hysicians are ultimately responsible for ensuring that medical records are stored and maintained
according to legal re$uirements and the principles set out in this policy.
@edical records must be stored in a safe and secure environment to ensure physical and logical
integrity and confidentiality. %hysicians must develop records management protocols to regulate
who may gain access to records and what they may do according to their role, responsibilities,
and the authority they have.
4.
-t minimum, protocols must ensure that patient records, in
electronic or paper form, are readily available and producible when legitimate use is re$uired,
and that reasonable steps have been ta1en to ensure they are protected from theft, loss and
unauthori(ed use or disclosure, including copying, modification or disposal.
45
This re$uirement
applies regardless of whether the information is stored on premises within the physicianBs control
or otherwise. 7hat is reasonable in terms of records management protocols will