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Charting for Podiatrists

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Professional Standards and Guidelines Regarding Charting for Podiatrists

Preamble

Good charting is an essential component of medical care. Good charting provides a foundation for good care by future providers unfamiliar to the patient.

Good charting is comprehensive, reflecting all relevant information and all care provided. Charts signed off on by podiatrists are presumed to be complete. In making this presumption, the College applies the axiom: “not documented, not done.”

The purpose of this document is to set out the College’s expectations with respect to charting. This document applies equally to paper-based and electronic medical records. The document applies to all clinical encounters, whether patients are seen in-person or virtually.

Professional Standards

General

Podiatrists must:

  1. Be mindful of the ambiguity of abbreviations and use universally accepted abbreviations;
  2. Maintain each specific patient’s chart in a chronological and systematic manner, ensuring that patient identification (i.e., name, date of birth, health card number (where appropriate), sex/gender information) and contact information (i.e., telephone number and address) are captured in all medical records;
  3. Document entries as soon as possible after the patient encounter;
  4. Ensure handwritten records are legible to others;
  5. Verify that the entries populated using a template accurately reflect each patient encounter with all pertinent details about the patient’s health status captured;
  Electronic record templates are useful for good patient care but may pose a risk if overly relied upon. Podiatrists should review and update prepopulated fields for each patient encounter. Podiatrists are expected to review prepopulated templates.  
  1. Ensure charting is comprehensive, containing:
  1. information that conveys the patient’s health status and concerns;
  2. any pertinent details that may be useful to the podiatrist or future healthcare professionals who may see the patient or review the medical record; and
  3. the rationale for the treatment or procedure provided;
  1. Ensure charting is factual and professional in tone.

Telephone and Electronic Communications with Patients

Podiatrists must capture details of all communication with patients related to clinical care that occur via telephone, or other digital means (e.g., e-mail, patient portals or other digital platforms), including the mode of communication in the medical record. Refer to the College’s Professional Standards Regarding Virtual Care for Podiatrists and Professional Standards and Guidelines Regarding Podiatrist Use of Social Media.

Editing Medical Records

  1. Where it is necessary to edit an inaccurate or incomplete medical record, Podiatrists must:
  1. record the time of the additions or changes;
  2. initial the additions or changes; and
  3. where changes are being made, whether on paper charts or an EMR, either:
  1. maintain the incorrect information in the record, clearly label it as incorrect, and ensure the information remains legible (e.g., by striking through incorrect information with a single line); or
  2. remove and store the incorrect information separately and ensure there is a notation in the record that allows for the incorrect information to be traced.
  In the context of legal or regulatory proceedings, podiatrists are encouraged to seek the advice of legal counsel before editing medical records.
  1. The podiatrist must notify any healthcare providers involved in the patient’s care if the change in charting would have an impact on that healthcare provider’s treatment decisions.
  2. Medical records shall not be altered after a complaint or legal action has been initiated unless a clinical fact is missing, and a clear late entry is made to the record as per this Standard.
  3. Podiatrists must respond to a patient’s request to edit a medical record. The decision to edit a medical record is a function of the podiatrist’s professional judgement. When responding to a patient’s request to edit a medical record, a podiatrist must either:
  1. follow the provisions provided in Standard 8; or
  2. when choosing not to edit a medical record in response to a patient’s request, the podiatrist must document the request in the chart, as well as the reasons for declining the request.

Guidelines

  1. Podiatrists should document the following for all patient encounters:
  1. presenting complaint;
  2. a focused relevant history;
  3. an assessment and an appropriate focused examination;
  4. a diagnosis and/or differential diagnosis;
  5. any treatment or therapy provided and the patient’s response and outcomes;
  6. a management and follow-up plan, including advice given to patients and/or care givers;
  7. any prescriptions issued in accordance with the College’s Professional Standards and Guidelines Regarding Prescribing for Podiatrists; 
  8. consent in accordance with the College’s Professional Standard and Guidelines Regarding Informed Patient Consent to Treatment for Podiatrists and any consent to treatment obtained in writing;
  9. all recommended and/or requisitioned tests and/or referrals made, including a copy of the referral note, and any associated reports and results (e.g., laboratory, diagnostic, pathology);
  10. any recommendations, treatments, investigations, or referrals that have been declined or deferred, the reason, if any, given by the patient, and discussion of the risks;
  11. any operative and procedural records; and
  12. any discharge summaries.

Definitions

Electronic medical records (EMR) means a computer-based patient record that is created digitally or stored digitally (e.g., a patient record that has been scanned). EMRs are real time records that make patient health information available instantly. Also known as an electronic health record.

Resources

College of Physicians and Surgeons of Nova Scotia

Canadian Medical Protective Association

Acknowledgements

The development of this College standard was informed by the College of Physicians and Surgeons of Ontario’s document Medical Records Documentation and the Colleges of Physicians and Surgeons of Manitoba’s Standard of Practice Documentation in Patient Records.

Document History

Approved by the Council of the College of Physicians and Surgeons of Nova Scotia on: March 21, 2025

© 2025 College of Physicians and Surgeons of Nova Scotia