Medical Record-keeping
Medical record-keeping is an integral part of medical practice, for it attests to the condition of the patient, the progress of the illness, and the conduct of the physician. The Collège places great importance on this aspect of medical practice and therefore groups together on this page several tools to facilitate the keeping of medical records.
Consulting Rooms and CLSCs
The guide entitled La rédaction et la tenue des dossiers par le médecin en cabinet de consultation et en CLSC enables physicians to apply the new regulations on record-keeping in various consultation settings. This document contains appended forms that may be taken out, photocopied and included as part of the medical record. These may also be downloaded in PDF format. (in French)
Healthy ABCs: Assessment from Birth to Childhood (0-5 years)
Sheets for your medical records are available in the Web site of the faculté de médecine de l'Université de Montréal.
General Care and Specialized Care Establishments
The practice guide entitled La tenue des dossiers par le médecin en centre hospitalier de soins généraux et spécialisés takes into account developments in medical practice at the level of science as well as delivery of care. It sets out the content of certain diagnostic examination reports and draws particular attention to the record’s summary sheet. It also includes sections on new realities, such as day medicine, telemedicine and computerized records.