Document ID: chunk:federal_register_of_legislation:F2022C01039:reg:6
Version: federal_register_of_legislation:F2022C01039
Segment Type: reg
Provision Reference: reg 6
Character Range: 6150–7047

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.