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 regulated member 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 regulated member 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 regulated member 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 regulated member 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 regulated member must discuss the fee for the NTME with the party requesting the examination.
- The regulated member undertaking the NTME must obtain informed consent from the person for the examination, diagnostic interventions and release of the physician’s report.
- Notwithstanding clause (4), the regulated member 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 regulated member 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 regulated member must not establish a therapeutic relationship with the person being examined unless:
- there is no other regulated member readily available to provide those services, and
- then only after concluding the process with the third party.
- If a patient requires urgent intervention, the regulated member must make arrangements for follow-up care through another regulated member who can treat the patient. If no other regulated member is available or there is no known treating regulated member, the regulated member 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 regulated member 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