Key Takeaways
- COTO reports record keeping as a frequent theme in complaints and registrar’s investigations.
- Most regulators publish specific documentation or record-keeping standards.
- Late entries must be clearly identified as late; originals must never be altered.
- Electronic audit trails show when entries were made or changed.
Published Standards
Examples include CNO’s Documentation practice standard, RCDSO’s Dental Recordkeeping guideline, CDHO’s Clinical Information Practice Standard, CRPO’s record-keeping and documentation standards, CPBAO Standard 9 (Records and Record Keeping) and CCO’s S-022 on records.
Lessons From Investigations
- If it is not documented, it is hard to prove it happened.
- Consent discussions should be recorded, not just assumed.
- Records should match invoices and billing.
- Altered records are treated very seriously.
Better Habits
- Document contemporaneously.
- Use dated addenda for corrections.
- Record key conversations, including phone and portal messages.
- Audit a sample of your own files periodically.
Frequently Asked Questions
Can I add notes after a complaint?
Only as clearly dated addenda that leave the original intact, and preferably after advice.
How long must I keep records?
Retention periods are set by each profession’s regulations and standards. Check yours.
Sources
Statutory references are to the provisions listed below, as consolidated on e-Laws when this page was prepared.
- COTO, “Investigations Data Overview: December 2024–May 2025” — Checked November 10, 2026.
- CNO, “Standards & Guidelines” — Checked November 10, 2026.
- CDHO, “Standards & Resources” — Checked November 10, 2026.
- CRPO, “Practice Standards” — Checked November 10, 2026.