Chart Completion

Timely completion of patient charting is a critical practice in today's delivery of healthcare services. First and foremost, it is necessary to have accurate and up-to-date clinical information for the patient care continuum. Although optimal patient care is the primary reason for efficient chart completion, there are other arguments for the judicious completion of clinical charts. For instance, physicians are required to have appropriate documentation in circumstances where provision of care or healthcare provider performance is under scrutiny including lawsuits; complaints to regulatory colleges; coroner reviews or inquests; and applications to the consent and capacity board. Clinical governing bodies have also influenced physician's chart completion. In 2005, the Ontario Medical Association outlined that the most responsible physician was accountable for the completion of a discharge summary within 48 hours of discharge (OMA Agreement 2005).

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