Both the regulations and good medical practise require that the information be organized in such a manner that it can be retrieved not only by the physician who creates the records, but by others. Further, the information should be legible, organized and intelligible. Records should reflect important discussions between the treating physician and patients, such as explanations of treatment options offered, together with a notation that appropriate explanations were given and discussions were had about the relative risk of proposed interventions. The final comment is on objectivity. Comments which might be seen as unflattering, personal observations on appearance or motivation of patients clearly have no place in the medical record.
Medical records are an important measure of the quality of care received by a patient.
By law, physicians are required to record certain information in their patients' records. College policy and good office practice also require that physicians follow particular procedures in the maintenance, transfer and eventual disposal of their records. This article also contains information on the disclosure of records, medical records and partnerships, obligations on closing a practice and storage of records on computer. For many years members of the profession have been advised to keep in their possession medical records generated by them for a period of some years. The Supreme Court of Canada decision of McInerney vs. MacDonald has clarified the law with respect to the disclosure of medical records by doctors to their patients.