What’s the same?

All Colleges require records to be accurate, legible and comprehensive. They also note the importance of uniquely identifying each record (as patients may have the same or similar names) and who provided care or made entries into the record.

What’s different?

Some Colleges require that patient identifying information be on every page of the record and/or specify that page numbers be used (in case pages become separated). Others require that the treating health professional include their contact information.

Some Colleges require the name of the referring health professional and/or primary care physician, which may or may not be applicable in all cases.

In Practice

At Willow Pines Rehab Clinic, Ingrid (occupational therapist), Carol (speech-language pathologist) and Greg (audiologist) work together on a regular basis. Their colleges have slightly different expectations about recording identifying information, page numbers and contact information. They decided it was good practice to align along the most detailed requirements, and agreed to adopt a format that meets all requirements.