Non-Treating Medical Examinations
Under Review: No
Issued by Council: January 1, 2010
Reissued by Council: May 23, 2013
This Standard of Practice is intended to be in addition to the requirements or obligations on a physician agreeing to undertake an NTME under the Minor Injury Regulation or an NTME under Rules 5.41 to 5.44 of the Alberta Rules of Court. The physician is also expected to act in accordance with the provisions of the Minor Injury Regulation and Alberta Rules of Court 5.41 to 5.44.
- When accepting a request to perform a Non-Treating Medical Examination (hereafter referred to as “NTME”), a physician must:
- treat the person under the same ethical obligations as would apply to any patient,
- provide an objective and scientifically sound report, and
- be aware of the terms of authority for the examination set out in contract, statute or Rules of Court, whichever applies.
- When agreeing to undertake a NTME, a physician must disclose to all parties:
- his or her involvement at any time in the medical care of the person undergoing the examination, and
- any relationship with the third party outside of a fee for service arrangement.
- In advance of the examination, a physician must discuss the fee for the NTME with the party requesting the examination.
- The physician undertaking the NTME must obtain informed consent from the person for the examination, diagnostic interventions and release of the physician’s report.
- Notwithstanding subsection (4), the physician is not legally required to obtain consent if a person has been ordered by a court order or statutory direction to undergo a NTME; however, the physician is not required to:
- enforce the terms of a court order or statutory direction, or
- proceed with an NTME if the person refuses to cooperate with the physician undertaking the NTME.
- A physician must not establish a therapeutic relationship with the person being examined unless:
- there is no other physician readily available to provide those services, and
- then only after concluding the process with the third party.
- If a patient requires urgent intervention, the physician must make arrangements for follow-up care through another physician who can treat the patient. If no other physician is available or there is no known treating physician, the physician must:
- promptly advise the patient of the particulars of the medical issue that re quires urgent attention, and
- provide necessary care if the situation is emergent or urgent and no alternative is available.
- The physician must retain the following records obtained or created for the NTME for a period of ten (10) years or longer if required by statute:
- the final report and any interim reports issued to the third party,
- informed consent document,
- contract (if it exists in written form) outlining scope, purpose, timeliness, and fee arrangements,
- notes of history,
- notes of physical examination,
- audio and video recordings if made by the physician,
- a list of sources of ancillary information, including medical reports, records, and any audio or visual information recorded by another person, and
- the name of any person who attended with the person being examined.
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