Good Records Protect You

When documenting patient care, it’s critical to include details of your conversations with patients, especially around informed consent, treatment options discussed, and advice provided. This isn’t just good practice; it’s your strongest protection in a complaint or investigation.

As reinforced in the Ontario court decision Kodsi v Health Professionals Appeal and Review Board, 2025 ONSC 2502 (CanLII), regulators and courts rely heavily on patient records as accurate reflections of what actually occurred during care. If it’s not documented, it may be assumed it didn’t happen. The court upheld a broad remedial order for a dentist because poor record-keeping raised concerns not only about documentation but about the quality of care itself.

Pro Tips

• Talked it out? Write it down!
  • Summarize the discussion with the patient in your clinical notes about treatment options, benefits, risks, and patient preference
• Consent isn’t just a form.
  • Note when and how consent was obtained and what was discussed
• Handouts = Helpful
  • If you gave the patient written material, say so in the notes, i.e., reviewed care instructions; copy provided
• Note your due diligence
  • Note any follow-up recommendations provided to support patient understanding
• Think ahead
  • Write your notes like someone else might read them later because they might

These practices ensure that when a complaint is reviewed, your file tells the full story. A well-documented chart can make the difference between a concern about documentation and a concern about your overall competence. For more information on recordkeeping and your responsibilities, review the Standards of Practice, Patient/Client Consent, and Recordkeeping Guidelines.