Elements Of Documentation

Unless it is inconsistent with other legislation covering the health record, an acceptable patient/client’s health record includes the following:

Documentation, or the lack of it, often plays a significant role in legal matters surrounding health care. In cases that are referred to the CRTO’s Inquiries, Complaints and Reports Committee (ICRC), it has been noted that the amount of documentation is frequently not sufficient to accurately reflect what took place. All too often, there is little or no record of event or the RTs role.

When it is necessary to correct an incomplete or inaccurate medical record, RT’s must:

There are practice settings where an RT may be required to dictate their reports or chart entries.  It is important that the reports generated are reviewed by the author for accuracy as soon as possible.  RT’s are encouraged to avoid the “dictated but not read” scenario.

Electronic Health Records (EHR) are electronic versions of the paper chart, and therefore, are subject to the same professional regulations and standards as paper records (Paterson, 2013). EHRs often differ from one organization to another; however, they share some common elements:

The use of electronic record templates, particularly those with pre-populated fields, poses risks to accurate and complete medical records. In keeping with documentation requirements, RT’s must verify that all entries are accurate, complete, and free from error. 

As the delivery of healthcare becomes more responsive and progressive, this type of communication has become vital.  Methods such as email, text messaging, along with virtual healthcare through video conferencing platforms and telemedicine are considered to be patient/client interactions.  Therefore,  this type of contact must also be documented according to the same principles and standards as other forms of documentation. It is also important to document the mode of electronic communication (e.g. text, email). In addition, measures must be taken to protect the safety and security of this confidential information, such as those outlined in the CRTO Standards of Practice. RT’s must “Protect against theft, loss or unauthorized use or disclosure of confidential patient/client personal information (e.g., passwords, encryption, systems for backup and storage, and processes for sharing/transferring information).

If RTs are providing care under the authority of a medical directive, it is important to reference this in the patient/client’s PHR and document the name and number of the medical directive. (e.g., Mechanical Ventilation Medical Directive, #00-001).

For more information, please see the CRTO’s Orders for Medical Care PPG.

Members who are employed in Ontario hospitals should be aware that the Public Hospitals Act states that patient/client health records must be maintained for at least 10 years from the date of last entry in the record. In addition, the health records of patients/clients who were under the age 18 at the time of the last entry ought to be retained for a minimum of 10 years from the day the patient/client turns 18.

RTs working in other practice settings are encouraged to confirm their employer’s policies regarding record retention and to refer to legislation that outlines record retention provisions.

To be understandable, records must use standard abbreviations and be correctly spelled. It is acceptable to use an abbreviation where it is spelled out in full the first time it is used in a notation. Whenever numbers are used, make sure units are included where needed to ensure there is no potential for misinterpretation. When referring to drugs and drug dosages you must always include the units along with any numbers.