Under Review: No
Issued by Council: July 1, 2011
Reissued by Council: June 11, 2015
- A regulated member providing episodic care1 must:
- inform the patient that the regulated member will not provide ongoing care beyond addressing the patient’s presenting concern(s), referred consultation, or identified medical condition(s);
- establish whether the patient has a primary care provider and, if so, provide the primary care provider with a record of the encounter, including all information discussed in clause (2);
- obtain and document the patient’s presenting concern(s) and/or medical condition(s);
- collect and document the patient’s relevant medical history, drug reactions, current medication(s) and pertinent current health problems;
- observe, examine and identify relevant positive and negative findings;
- establish a reasonable differential diagnosis; and
- either provide necessary follow-up care personally or ensure that arrangements are in place for follow-up care.
- A regulated member must discuss with the patient:
- tests requested;
- diagnoses reached;
- treatment and advice given;
- procedures recommended and performed;
- referrals and reports made; and
- follow-up care arranged and/or advised.
- A regulated member who has provided episodic care must document the encounter in accordance with the Patient Record Content standard of practice.
- A regulated member who requests a diagnostic test(s), performs a procedure or provides a treatment that requires follow-up, or makes a referral to another healthcare provider must:
- have a system in place to:
- review and respond to any diagnostic test results and/or consultation reports arising from this encounter;
- review and respond promptly to critical test results reported by a laboratory or imaging facility, including after regular working hours or in the regulated member’s absence;
- arrange any necessary follow-up care either personally or through referral to another healthcare provider; and
- notify the patient of any necessary follow-up care; and
- track all contacts and attempted contacts with the patient.
- have a system in place to:
- A regulated member who requests a diagnostic test and directs a copy of the result to another regulated member remains responsible for any necessary follow-up care unless the regulated member to whom the copy is directed has formally agreed to accept responsibility for follow-up care arising from the test results.
1Episodic care refers to a single encounter with a patient focused on a presenting concern(s), identified medical condition(s) or referred consultation, where neither the regulated member nor patient have the expectation of an ongoing care relationship.
The CPSA Standards of Practice are the minimum standards of professional behaviour and ethical conduct expected of all physicians registered in Alberta. Standards of practice are enforceable under the Health Professions Act and will be referenced in the management of complaints and in discipline hearings. About the CPSA Standards of Practice