Law 3101A/B Chapter Notes - Chapter 9: Vancouver Coastal Health, District Health Board, Regulatory College
Document Summary
The record includes all clinical information about a patient, howsoever recorded. The driving force in record keeping is not the law, but rather the patient"s clinical needs (at a minimum) (i. e. a record allows for ongoing quality care will be sufficient for legal purposes). Record: must contain all treatment, counsel, and care of a patient, regardless of the form it is recorded in (e. g. electronic, paper) a patient has all the right to access their record. The record should permit a third person to recreate what you saw, heard, did, and why you did it. If another professional were to take the file, would they be able to continue the quality of care for the patient (allow continuity of care) A (cid:396)e(cid:272)o(cid:396)d (cid:373)ust pe(cid:396)tai(cid:374) to the autho(cid:396)"s (cid:448)ie(cid:449)s. (b) legal importance of record keeping policies and practices. It is (cid:271)e(cid:272)ause of this p(cid:396)i(cid:374)(cid:272)iple (cid:894)p(cid:396)esu(cid:373)ed to (cid:271)e t(cid:396)ue(cid:895) that (cid:862)(cid:272)ha(cid:396)ti(cid:374)g(cid:863) is assu(cid:373)ed to (cid:271)e a means of consent.
