Whenever educators and advisors discuss the importance of record keeping, they often haul out the old chestnut “if it wasn’t recorded, it wasn’t done” (or as the kids would say now “pics or it didn’t happen”). The idiom reinforces the importance of recording the details of obtaining informed consent, the options considered, and the advice given to a client, among other things. A recent Ontario Divisional Court decision illustrates that the expression is not simply a scare tactic or oversimplification used to motivate registrants to document better in order to avoid civil liability.
In Kodsi v Health Professionals Appeal and Review Board, 2025 ONSC 2502 (CanLII), a dentist was required to complete a comprehensive remedial program, which broadly covered several areas of substantive practice skills. The dentist argued that the remedial program should be scaled down since the concerns were “only” about gaps in communication and record keeping. Everyone seemed to accept the general principle that a remedial program should only cover identified areas of concern. The Court upheld the scope of the remedial program because the regulator’s concerns were substantive and wide-ranging.
On the issue of whether the concerns were just about record keeping and communication, the Court said:
[6] First, HPARB explained that the concern about Dr. Kodsi’s record-keeping and communication reflected broader concerns about his practice. At para. 50 of its reasons it emphasized that, in the absence of compelling information, dental records are treated as an accurate reflection of what occurred:
…[D]ental records are legal documents that all dentists are required to make. Dental records provide a contemporaneous record of interactions with a patient, made prior to the commencement of any complaint or legal process. As such, in the absence of compelling information to the contrary, dental records are a reliable source of information as to what occurred during the patient encounter.
[7] HPARB therefore read the Committee’s comments about record-keeping to reflect not only a concern about documentation, but also about Dr. Kodsi’s substantive practice. This was a reasonable reading of the Committee’s decision and a fair reflection of the role and importance of record-keeping.
The Court accepted that the gaps in the records supported several concerns about post-surgical management and possible inadequate instructions and advice given to the patient,
Gaps in record keeping can result in professional accountability as well as civil liability.