What to document medical records content physicians must ensure that patient identification ie name date of birth ohip number gender information and contact information ie telephone number and address are captured in all medical records 10 physicians must date each entry in the medical record. The medical records documentation policy requires primary care physicians to include a cpp or an equivalent patient health summary in each patient medical record and requires all other physicians to use their professional judgement to determine whether to include one the policy sets out considerations for determining whether a cpp is required. A medical record documentation template is written by a qualified doctor of health care or physician provides accurate and complete information about the medical history diagnosis as well as treatment of patient normally these documents are the proof and record of the patients health and every medical related incident happened to patient since birth a well written medical record . Providing access to medical records physicians must provide patients and authorized parties 6 with access to or copies of all the medical records in their custody or control upon request unless an exception applies 7 8 where an exception applies and access is refused physicians must inform the individual in writing of the following
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