For the purpose of this PPG, the term ‘Personal Health Record’ or ‘PHR’ refers to the record of clinical care provided to the patient/client, including (but not limited to):
equipment maintenance records;
The CRTO’s Standard of Practice, which outlines the expectation of RTs when documenting states that:
“Patients/clients can expect that RTs keep complete, clear, timely, objective, and accurate records of the care provided and that privacy/confidentiality is protected.”
This Documentation PPG is intended to provide Members with information on the CRTO’s expectations related to documentation. The CRTO has also developed several other relevant PPGs that may have complementary and overlapping information related to documentation, such as:
“Only the information contained within a patient’s chart can be used in a court of law”.
All patient/client information that is either electronically or paper generated is part of the personal health record and can potentially be used in a court of law.
RTs may select any style of charting that fits with their practice, provided that it adheres to both the standards, expectations and requirements of both the CRTO and the employer.
Examples of different charting styles are:
The Purpose of Documentation
The primary purpose of documentation is to facilitate ongoing communication that supports the continuity, quality and safety of care. As a key mode of communication, any health care provider reading the PHR must be able to understand what has taken place, who was involved and what the outcome for the patient/client was. An accurate and comprehensive record of the patient status, interventions and responses helps to facilitate collaborative decision-making regarding the ongoing treatment plan.
Evidence of Care
Documentation also serves as written evidence of the care provided to the patient/client. Complete, accurate and objective documentation is important for many reasons; one of which is that it provides essential evidence that is often required in legal proceedings (e.g., civil court), as well as the CRTO’s complaints and discipline process.
Research & Quality Improvement
Aggregate data collected from a patient’s PHR (e.g., chart audits; length of stay (LOS) audits) provides valuable information for health research activities. This research contributes to Continuous Quality Improvement (CQI) initiatives (e.g., Asthma Care Pathways, readmission outcomes) that are aimed at improving health care outcomes for all patients/clients.
The Principles of Documentation
Documentation is effective when it enables members of a patient/client’s health care team to have access to the information needed to deliver optimal patient/client care (for both present and future needs). Regardless of the practice setting (ICU, home care, emergency, outpatient clinic, primary care, operating room (OR), diagnostics, research), the principles of PHR documentation are the same. The CRTO acknowledges the difficulties often associated with documenting in areas such as the OR, emergency, home care and patient transport. However, we encourage all CRTO Members to work with their employer to find solutions to these challenges.
Effective documentation forms the basis of any PHR and must be:
Clear, concise, comprehensive and courteous;
Identifiable, containing a signature or audit trail that identifies the author;
Entered in a manner that prevents or deters alteration.
For example… If three (3) attempts are required to successfully intubate a patient, then all three (3) attempts should be documented.
Patient/Client Contact Defined
The professional standard of practice is that every contact between an RT and a patient/client must be documented. A patient/client contact can include contact for the purposes of:
performing an examination, diagnostic procedure, therapeutic intervention; or
providing education to a patient/client and/or their family, caregiver or advocate.
For example…Conferring with other members of the health care team (including the patient/client’s family members) regarding their orders or medical status is also considered to be a patient/client contact.
It is important to note that patient/client contact includes not only direct patient/client care, but also indirect contact regarding a specific patient/client, such as communication via:
Electronic (including text, social media)
Virtual (including video conference and telemedicine)
* For information on the use social media in professional practice, please view the Use of Social Media by Respiratory Therapists Fact Sheet
Confidentiality & Privacy of Personal Health Records
All RTs must respect and protect patient/client confidentiality and privacy in every aspect of their practice. RTs can only share patient/client information with the consent of the patient/client, or as required where permitted by law. Personal health information should only be shared within the “circle of care” in the following circumstances:
If required by law (e.g., as part of an investigation under the Regulated Health Professions Act, reporting of suspected child abuse under the Child and Family Services Act); or
To disclose a risk of harm as enabled under PHIPA section 40 (1) Disclosures related to risks, which states that:
40 (1) A health information custodian may disclose personal health information about an individual if the custodian believes on reasonable grounds that the disclosure is necessary for the purpose of eliminating or reducing a significant risk of serious bodily harm to a person or group of persons.
PHIPA provides specific guidance for handling the collection, use and disclosure of personal health information by information custodians. RTs who are employees of hospitals, or most other facilities, are not custodians but “agents” of organizational custodian. Therefore, it is the organizational custodian (employer) who is responsible for developing policies and procedures for the collection, use, disclosure and protection of personal health information under PHIPA, and for ensuring compliance. As an agent, the RT must comply with the custodian’s privacy practices when acting on the custodian’s behalf, unless otherwise permitted by law.
Circle of Care –
Sharing Personal Health Information for Health Care Purposes
The term “circle of care” is not defined in PHIPA. However, it is a term commonly used to describe the ability of certain health information custodians to assume an individual’s implied consent to collect, use or disclose personal health information for the purpose of providing health care, in circumstances defined in PHIPA.
To find out more visit the Information and Privacy Commissioner of Ontario website.
It is the organizational custodian (employer) who is responsible for developing policies and procedures for the collection, use, disclosure and protection of personal health information under PHIPA, and for ensuring compliance. As an agent, the RT must comply with the custodian’s privacy practices when acting on the custodian’s behalf, unless otherwise permitted by law.
Members are reminded that confidentiality is not limited to sharing of health records with others, and should consider other potential breaches, such as:
Discussing a patient/client in a public place such as elevator/cafeteria;
Viewing a patient’s health record without authorization (including your own or that of a family member); and
Leaving a patient’s health record unattended where it can be viewed by others (including a computer screen).
While less secure and reliable, many healthcare organizations continue to rely on fax machines for the transmission of patient information. Members should take extra care when faxing and receiving faxes containing personal health and other confidential information by ensuring:
There is a confidentiality message on the fax cover sheet indicating that the information is confidential and if received in error the sender should be contacted and the fax destroyed securely without being read;
The fax number is confirmed by the recipient and double-checked by sender;
Recipients are called in advance when a highly confidential fax is being transmitted;
Receipt of fax is confirmed by the recipient;
The fax machine is securely located;
Incoming faxes are distributed on arrival;
Outgoing fax cover sheets are marked “confidential”; and
Any outgoing fax is collected after transmission.
“Giving information about a patient or client to a person other than the patient or client or his or her authorized representative except with the consent of the patient or client or his or her authorized representative or as required by law” is considered to be professional misconduct. (s.11 Professional Misconduct, O.Reg. 753/93).
When transporting confidential PHRs (e.g., from a home care company’s office to patient/client homes), Members should ensure that PHRs are kept out of sight and that vehicles are securely locked.
Agents (of the Health Information Custodians): defined in the Health Care Consent Act (HCCA) in relation to a health information custodian, as “…a person that, with the authorization of the custodian, acts for or on behalf of the custodian in respect of personal health information for the purposes of the custodian…”
CRTO Member: A Respiratory Therapist who is registered with the CRTO; including Graduate Respiratory Therapists (GRT), Practical (Limited) Respiratory Therapists (PRT) and Registered Respiratory Therapists (RRT).
Charting By Exception (CBE): a charting system used in patient/client health records. CBE requires a detailed plan of care map, and includes flowsheets, graphic records and progress notes that may take the format of SOAP/SOAPIE(R) (Subjective, Objective Data, Assessment, Plan, Intervention, Evaluation, and Revision).
Focus Charting System: a charting system which includes flow-sheets, checklists and progress notes that take the format of DARP (Data, Action/Analysis, Response, and Plan).
Health Information Custodian (HIC): defined in the HCCA as “…a person or organization described in one of the following paragraphs who has custody or control of personal health information…”.
Medical Directive: a medical order for a range of patient/clients who meet certain conditions. The medical directive is the order and should therefore meet the criteria for a valid medical order.
Narrative Charting: when data is recorded as progress notes, supplemented with plan of care flow sheets.
Personal Health Records (PHR): the record kept by HICs who provide health care and may be in either a paper-based or computerized format.
Primary Care: including, but not limited, to Family Health Teams, Community Health Centres, various agencies, such as the Canadian Mental Health Agency.
Problem-Oriented Charting (POHR): charting system which includes a plan of care, problem list and progress notes/discharge plans which take the format of “SOAP/SOAPIE” (Subjective data, Objective data, Assessment data, Plan, Intervention and Evaluation).
- Cavoukian, A. (2009). Circle of care: Sharing personal health information for health care purposes. Retrieved from Information and Privacy Commissioner Ontario website: https://www.ipc.on.ca/images/Resources/circle-care.pdf
- College of Nurses of Ontario. (2008). Documentation. Practice Standard. Retrieved from http://www.cno.org/Global/docs/prac/41001_documentation.pdf
- College of Physicians and Surgeons of Ontario. (2020). Medical records. Policy Statement (#4 – 12). Retrieved from https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Medical-Records-Documentation
- College of Physiotherapists of Ontario. (2017). Record Keeping Standard. Retrieved from https://www.collegept.org/rules-and-resources/record-keeping
- Cox, K., Moghaddam, N., Almack, K. et al. Is it recorded in the notes? Documentation of end-of-life care and preferred place to die discussions in the final weeks of life. BMC Palliat Care 10, 18 (2011). https://doi.org/10.1186/1472-684X-10-18
- Paterson, A. M. (2013). Medical Record as a Legal Document Part 2: Meeting the Standards. Journal of Legal Nurse Consulting, 24(1), 4-10. Retrieved from http://www.aalnc.org/?page=JLNC