Law 3101A/B Chapter 9: HCL - CHAPTER 9
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 treatment needs (i. e. a record that provides for ongoing quality care will be suf cient 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. A record of a rash or immature patient should be more detailed and extensive than that of a stable, longtime 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: the legal importance of record keeping policies and practices. Good records minimize mishaps that result in litigation, short circuit frivolous, trivial claims, and assist in responding to the increasing number of demands for access to the record.
