Health Sciences 3101A/B Chapter Notes - Chapter 8: Microform, Retention Period, Personal Information Protection And Electronic Documents Act
12 Dec 2016
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Document Summary
The record includes all clinical information about a patient, howsoever recorded. The driving fore in record keeping is not the law, but rather the patients treatment needs (i. e. a record that provides for ongoing quality care will be sufficient for legal purposes) The level of detail should increase with the: seriousness of the problem; risks of treatment; novelty of the treatment; and challenging character of the patient. The record should permit a third person to recreate what you saw, heard, did and why you did it. The record should permit continuity of care: legal importance of record keeping policies and practices. Good records minimize mishaps that result in litigation, short circuit frivolous, trivial claim and assist in responding to the increasing number of demands for access to the record. Penal consequences: provincial offences, federal crimes. Professional consequences: artinian vs. college of physicians and surgeons of ontario, hasan vs. college of physicians and surgeons (n. b. , civil liability for negligent record keeping.
