Elements Of Documentation
Content of the Patient/Client Personal Health Record
Unless it is inconsistent with other legislation covering the health record, an acceptable patient/client’s health record includes the following:
Unique patient/client identifiers, such as the patient/client’s name and home address;
Most responsible physician(s) (MRP) or other health professional(s), such as the name of the primary care physician;
Reason for referral and diagnosis, if applicable; and
Clinically relevant information regarding the patient/client, such as the date and time for each patient/client contact.
Inaccurate, Incomplete or Falsified Documentation
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.
There have been several cases brought to the CRTO’s attention where an RT has intentionally falsified a patient/client’s PHR. This is a very serious offense, and it is essential that Members understand that the following is considered to be professional misconduct:
“Falsifying a record relating to the member’s practice”. (s.16 Professional Misconduct, O.Reg. 753/93).
Corrections to the Medical Record
When it is necessary to correct an incomplete or inaccurate medical record, RT’s must:
Maintain the incorrect information in the record, label as incorrect (e.g. a strike through) and ensure that the information remains legible
Date and initial the additions or corrections
Notify any health care provider who may be impacted by the incorrect information
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)
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:
unique identifiers (login and electronic signature);
audit trail to prevent alternation;
mechanisms to ensure security, privacy and confidentiality;
system for backup and storage of data; and
process for sharing and transferring information.
Use of Templates
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).
Keeping login information confidential, passwords strong, and changing this information to align with your employer’s policy;
Sign off devices when not in use
Using ID’s, rather than patient identifiers, such as names, when communicating electronically; and
Encrypting emails and/or other documents being transferred electronically that contains personal health or other confidential information.
Medical Directives and RT Protocols
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.
Retention of Personal Health Records
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.
Abbreviations may vary among different practice environments. It is the Member’s responsibility to ensure that the abbreviations being used are accepted in the facility where the record is being used. The CRTO does not provide a list of acceptable abbreviations.
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