The Importance of Contemporaneous Notes
For regulated health professionals, recordkeeping is not only an extremely important skill, but also a professional obligation. Recent case law demonstrates the importance of keeping good records, and specifically that notes prepared contemporaneously will be viewed as more reliable and accurate.
In a recent decision from the Health Professions Appeal and Review Board (HPARB), Flannery v. Ahmad, the HPARB was asked to review a decision of the Inquiries, Complaints and Reports Committee (the Committee) of the College of Physicians and Surgeons of Ontario. The decision concerned a complaint about a physician and the medical care he provided to a patient. The Committee investigated the complaint and decided to take no action.
The Committee only considers documents and written submissions. The physician and the patient had differing accounts of what occurred. In these situations, the Committee must rely on independent information to either confirm or refute either party’s version of events. The Committee reviewed the physician’s records, ultimately concluding that there was no information to suggest that the physician’s surgical approach was inappropriate. The Committee wrote:
Contemporaneous medical records are a reliable source of information as to what occurred during a medical encounter, particularly when the Committee is considering and attempting to reconcile differing recollections of the parties. Notes dictated at or near the time of events tend to provide a more accurate reflection of what occurred than does unaided human memory.
The HPARB considered the Committee’s findings and found that the Committee’s decision to take no further action was supported by the patient record, noting that the physician’s notes were detailed and comprehensive and that this supported the Committee’s reliance on the notes to determine what was and was not discussed between the parties.
This is not the first time that the HPARB has taken this view. In a 2025 decision, R.H. v Proctor-Cuggy, involving a complaint made to the College of Registered Psychotherapists and Registered Mental Health Therapists of Ontario, the HPARB noted that health records “provide a contemporaneous record of the interactions with the patient” and that they are a reliable source of information as to what occurred during patient encounters in the absence of compelling information to the contrary.
Key Takeaway
In the event of a complaint or investigation, patient records will be scrutinized by the regulator, and poor recordkeeping can result in regulatory action. The case law indicates that contemporaneous notes taken either by the health professional or a responsible, delegated staff member in the health professional’s practice are often viewed as more reliable and accurate when responding to an investigation. Health professionals should invest time and training into ensuring that their records are sound and aligned with the guidance from their College.
If you are a health professional who has received a complaint or has a question about recordkeeping, please contact us.
