Chapter 9 Documentation and Related Issues

imissyou419's version from 2017-11-30 07:01


Question Answer
Adequate patient record includesall clinical information about a patient, howsoever recorded
The driving force in recording keepingnot the law, but the patient's 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:seriousness of the problem, risks of treatment, novelty of treatment (new patient), challenging character of the patient
The record should permit a third party to recreate what you saw, heard, did, and why you did it, and permit continuity of care
What are the benefits of having good records?minimize mishaps that result in litigation, short circuit frivolous, trivial claims, and asset in responding to the increasing number of demands for access to the record
T/F the public record is admissible in evidence and factual statements in the public record, if made contemporaneously with provision of the service, are persumed to be trueT, the SCC has held that a record made contemporaneously with the treatment will be considered prima facie proof of the factual statements made therein
T/F records can be used in testifyingT, a practitioner is allowed to use the record to refresh his/her memory in giving testimony as it will increase practitioner's credibility
T/F state of the record does not reflect on the professionalism and credibility of its authorF, it will. If sloppy or incomplete, suggest the practitioner is careless
T/F records are particularly critical in counselling because there is no physical evidenceT, in counselling there will rarely be physical evidence and it normally takes place in private absence of third party witnesses
T/F federal criminal law and various provincial law do not have statutory obligations to make and maintain record, it's up to the physicianF, federal criminal law and various provincial laws create statutory obligations to make and maintain records
T/F failure to keep adequate records is a specific ground for professional misconduct for various treatment professionalsT
What should the record provide?a comprehensive, accurate, honest assessment of what the practitioner observed, saw, considered, did, and why he/she did it even when pressured by patients, employers or others to support their preferred outcome
Guidelines for record keeping- objective professional tone,
- entries in chronological order,
- alterations and corrections made openly, with original entry left in tact,
- all corrections initiated, signed, dated,
- except in the case of a sole practitioner, health professionals should print and sign their name and indicate their position,
- written records in dark ink and legible,
- records should be complete, any omissions = negative,
- limit the record to relevant info to patient's treatment,
- the more sexually, legally or emotionally sensitive the info, the more important it is to ensure the info is relevant,
- relevant info should not be omitted b/c it is embarrassing or negative. Omitting relevant info exposes a professional to needless legal challenges.
- info should be recorded when the intervention is undertaken, or ASAP after. The longer the delay = more likely the record will be challenged,
- entries should be made by person providing service,
- if entries made by 3rd party -> should be verified by person who performed service
What are the consequences of falsifying records?civil liability, professional disciplinary action, prosecution under provincial law, possible criminal charges for perjury, fabricating evidence, forgery, and fraud


Question Answer
T/F practitioners are not governed by a complex "patchwork" of common law, equitable and statutory record keeping, confidentiality, disclosure, and patient access provisionsF, they are
What are the 3 sets of principles health practitioners are subject to?1. common law and equitable obligation to patients, the breach of which may result in being held civilly liable,
2. professional obligation to a regulatory college or body, the breach of which may result in being reprimanded, suspended or otherwise disciplined,
3. numerous federal and provincial statute provisions, the breach of which may result in prosecution
What are provincial statutes that apply to a single type of institution or service?Education Act, Child and Family Services Act (CFSA), Public Hospital Act (PHA), Mental Health Act (MHA)
What are provincial statutes that regulate broader categories of agencies and individuals?FIPPA and MFIPPA; and PHIPA
FIPPA (Freedom of Information and Protction of Privacy Act) and MFIPPA (Municipal Freedom of Information and Protection of Privacy Act) applies to who?essentially identical provisions and apply to virtually all PROVINCIAL and MUNICIPALLY-created government agencies, respectively
FIPPA - provincially created government institutions incl. Ministry of Health, public and psychiatric hospitals, universities, colleges, and Ontario Provincial Police
MFIPPA - municipally created government departments incl. municipal governments, board of health, school boards, municipal police departments
What are the 2 broad functions of FIPPA and MFIPPA?1. provide individuals the right to access general and personal info held by government institutions,
2. seeks to protect privacy by restricting government institution's authority to collect, use, and disclose personal info
e.g. the Act prohibits the collection of personal info unless it is expressly authorized by statute, used for law enforcement purposes, or is necessary for the administration of a lawfully authorized activity
Which people do FIPPA and MFIPPA not apply to?do not apply to practitioners working exclusively in the private sector or their regulatory colleges or governing bodies e.g. a nurse employed by a physician in private practice
PHIPA (Personal Health Information Protection Act) applies to who?collection, use and disclosure of personal health info by all HICS (virtually all health professionals and institutions) - all regulated health practitioners, members of college of social workers and social service workers, community care access centres, long term care homes, public and private hospitals, psychiatric and mental health facilities, evaluators, assessors, medical officers of health

Whether PHIPA directly applies to a specific individual may be of greater theoretical than practical significance b/c almost all of the Act's provisions apply to anyone who receives personal health info from a HIC; and many agencies have adopted PHIPA as part of their management policies and thereby require all employees, consultants, and service providers to comply with it
Which people do PHIPA not apply to?HIC does not include youth workers, addiction counsellors, school guidance counsellors
Personal health infoinfo that may directly or indirectly identify an individual relating to his/her physical or mental health, health number, or SDM, and health care providers
HIC may only collect, use or disclose personal health info ifthe individual consents and collection, use or disclosure is required for a lawful purpose, or the act permits or requires the collection, use, or disclosure
T/F Notwithstanding/in spite of PHIPA, QCIPA permits the disclosure of any info to a "quality of care" committeeT
QCIPA (Quality of Care Information Protection Act)greatly limits access to "quality of care" info and makes it inadmissible in any provincial proceedings
PIPEDA (Federal Personal Info Protection and Electronics Doc Act) who does it apply to?applies to the collection, use, and disclosure of personal info in the course of commercial activities (e.g. selling, bartering or leasing of donor, membership or other fundraising lists); applies to both public and private sectors across Canada; unlikely PIPEDA will apply to health professionals
T/F federal government may exempt agencies and individuals from its application if there is substantially similar provincial privacy legislation in placeT, PIPEDA has been displaced by comparable provincial privacy legislation in 5 provinces. In Ontario, PHIPA has been deemed to be substantially similar to PIPEDA, but not the 2004 version of QCIPA. It is yet to be decided if the 2016 version of QCIPA is substantially similar to PIPEDA
A nurse employer in Ontario public hospital is governed by what?common law, PHA, Regulated Health Professionals Act, FIPPA, PHIPA
T/F Key common law, equitable and statutory principles are not very similarF, key common law, equitable and statutory principles are very similar, which means the agencies can develop a single set of policies that simultaneously meet all of their overlapping record keeping, confidentiality, access, and disclosure obligations. These principles are wholly compatible with the current practices and ethical obligations of health professionals


Question Answer
Who owns the patient record?owned by practitioner or his/her employer
Do patients have a broad common law right of access to their treatment records, including confidential info provided by 3rd parties?Yes, unless a statute or contract provides otherwise or practitioner can convince a court to limit access. Patient can invoke this common law right by simply requesting. The common law right of access is in addition to the patient's right of access pursuant to a statute or court order.
Practitioners not required to provide a patient w/ original record or immediately comply with unexpected request
T/F Access under PHIPPA is more limited than under common lawT,
a patient may be denied access to his/her personal health info:
where granting access could be reasonably expected to create a risk of serious harm to the individual's treatment or recovery, or a risk of serious bodily harm to the individual or another person, and
where granting access could be reasonably expected to lead to the identification of a person who was legally required to provide info to the custodian, or a person who provided info in confidence
Who owns administrative records?owned by agency that creates them
Do patients have a common law right of access to administrative records, even if they contain info about them?No, practitioners and agencies can refuse to disclose an administrative record to a patient, unless they are required to do so by a statute (e.g. MFIPPA, FIPPA, PHIPA) or a court order
What are the 3 factors that need to be considered in setting record retention policies?1. statutory record retention requirements e.g. under PHA, public hospitals required by statute to keep record of patient for 10 years after death or discharge (for minor, 10 years after they hit 18),
2. statute of limitations for civil suits and the fact that it may only begin to run long after the wrong was committed,
3. other needs for the record, such as professional disciplinary proceedings, financial and tax purposes, criminal proceedings
What formats can health records be kept as?unless a statute provides otherwise, health records may be kept in a computer, written, microfiche, or other format.
The general rules of record keeping apply equally regardless of format.
Computer and microfiche format viewed as more reliable if author is identified, record dated, secure, permanent and unaltered w/o detection
How should statements of opinion be recorded?may be included in a patient record, but must be stated as an opinion.
The facts, observations, and patient statements upon which the opinion is based should be included in the record.
Opinions should be limited to matters of general knowledge, and issues that are within the scope of the practitioner's expertise, training, and experience
Is there a common law principle requiring or preventing practitioners from making a private record of their patient interactions?No, unless a statute or management policy provides otherwise
What makes a private record private?kept separate and apart from public record which are maintained for author's exclusive use, inaccessible to others (responsibility to make sure secure)
Are private records automatically admissible in evidence?No, private records are not automatically admissible and are not presumed to be true, unlike comparable statements in the public record
T/F if a practitioner keeps a good private record, he/she does not need to maintain a comprehensive public recordF, it does not diminish her legal responsibility to ensure the public record is comprehensive and complete
Can private records be subpoenaed?Yes, it can be seized under court order. Any discrepancy b/w the public and private record will undermine the practitioner's credibility and integrity
Information about a 3rd part can be recorded if the info is:reasonably credible, potentially relevant to the patient's treatment, properly attributed to its source.
Failure to record such info may give rise to liability in negligence e.g. patient's dad died from heart disease at 50
Is there anything in law that prohibits against using e-mail for communication?No, it is matter of management policy. Advisable to obtain patient's expressed consent to means of communication