Medical Records are integral to patient care and as such are central to a number of professional obligations.  For example, accurate charting supports informed decision-making and protects registrants in audits or medico-legal reviews. Proper record management ensures trust and transparency, reinforcing the registrant’s role as a custodian of sensitive health information.

The following professional standards are provided below as relating to a registrant’s obligation in managing medical records, in charting patient encounters and when using artificial intelligence (AI) scribes.

• Professional Standards Regarding the Management of Medical Records
• Professional Standards and Guidelines Regarding Charting
• Professional Guidelines Regarding Artificial Intelligence (AI) Scribes in Clinical Care

Registrants are expected to adhere to the CMA’s Code of Ethics and Professionalism and the recommendations of Choosing Wisely Canada both of which have been endorsed by the College of Physician and Surgeons of Nova Scotia (the College).

Registrants are expected to stay current with the College’s standards and guidelines.

Medical Records Management

The Professional Standards Regarding the Management of Medical Records explains the responsibilities registrants have regarding medical record access, transfer, retention, destruction and storage.

Registrants are responsible for the security and maintenance of the medical record. While registrants own the records, patients have an enduring right to access them, even after the physician-patient relationship ends. The College requires processes that guarantee this access, including agreements in group practices for continuity.

Transfers of records must be secure, documented, and accompanied by reasonable fees when applicable. Compliance with legislative requirements, such as the Personal Health Information Act, is mandatory.

Charting

The Professional Standards and Guidelines Regarding Charting emphasize that good charting is an important part of quality medical care. The College emphasizes that charts must be comprehensive, chronological, and factual. Registrants should document encounters promptly, avoid ambiguous abbreviations, and ensure accuracy when using electronic templates.

All communication, whether in person, by phone, or digitally, must be recorded in the patient’s chart. The guiding principle is clear: “Not documented, not done.” Having accurate and complete charts ensures future providers have a complete picture of the patient’s health status and care decisions.

AI Scribes in Clinical Care

The Professional Guidelines Regarding Artificial Intelligence (AI) Scribes in Clinical Care supports the use of AI scribe technology in clinical settings, recognizing its potential to enhance documentation, reduce administrative burden, and improve patient care.

Registrants using AI scribes must ensure the accuracy of medical records, obtain patient consent if recordings are maintained, and safeguard privacy and security. The guidelines emphasize reviewing AI-generated content for completeness, acknowledging potential inaccuracies, and informing patients about the scribe’s role. These standards align with existing legal obligations under Nova Scotia’s Personal Health Information Act and reflect the evolving nature of generative AI in health-care documentation.