Medical records & documentation

Providers should follow all documentation standards they would follow for in-person encounters. Documentation should comply with accepted professional standards.  It is expected that all medical records will be completed as soon as possible after the encounter, and no later than 24 hours.  All interactions with the patient or regarding the patient should be recorded within the patient record.  

When making notes in the patient record a provider should remember: A patient’s medical record is written evidence of the quality of care delivered to patients. All notes should be created with the expectation that the patient has the right to access their chart and receive copies of their chart.  For these purposes the ‘chart’ has been legally defined as all communications, including private communications, regarding the care of the patient.   

Rocket Doctor provides HIPPA and PIPEDA compliant mechanisms to access, create and transmit information.  When attending Rocket Doctor patients, providers are expected to use the Rocket Doctor platform and tools to access, create, or transmit information protected by legislation.  Providers are expected to be completely familiar with all relevant privacy rules, regulations and laws in the jurisdiction they practice.  Providers are expected to be fully compliant with these rules, regulations and legal requirements.  If a provider becomes aware of a privacy breach they are expected to immediately report the violation to the Privacy Officer, harry@rocketdoctor.io.  

Providers are not permitted to copy or transmit any records or documents, regarding patients or corporate matters, without the expressed written permission of Rocket Doctor.

For an opportunity to learn more about patient privacy and confidentiality, please see the eLearning activity from the Canadian Medical Protection Agency by clicking HERE 

Furthermore, if you’d like to gain further training Ontario Health has a Privacy and Security Training Module that is free to access HERE.

If you encounter any technical difficulties while accessing a patient's medical record, please contact our admin staff at admin@rocketdoctor.io, or for immediate assistance, click “Get Help” in the MD Portal for support.