Law 3101A/B Lecture Notes - Lecture 9: Microform, Retention Period, Endangerment
Document Summary
Court likely view patient record as including all recorded information held by hp/agency related to patient"s treatment. Hp have discretion in terms of range of information - but minimum the record of should contain all information necessary to coordinate and carry out patient"s treatment. Specific content and level of detail should be based on patient"s needs (more serious problem the greater the risk, therefore extensive recording keeping) Level of detail also reflect hp"s assessment of patient (new, immature, rash or manipulative = more information and as treatment is started - collect background information and identify patients concerns) Decreases once treatment plan has been decided and implemented. Therefore it will meet legal purpose (clinical needs for ongoing, quality care) To be adequate for legal purposes, record must provide for ongoing, quality care. It is the patient"s clinical needs and not the law that is the driving force in record keeping.
