{"id":3458,"date":"2021-12-12T23:17:51","date_gmt":"2021-12-12T23:17:51","guid":{"rendered":"https:\/\/documentation.crto.on.ca\/?page_id=3458"},"modified":"2021-12-13T00:34:18","modified_gmt":"2021-12-13T00:34:18","slug":"elements-of-documentation","status":"publish","type":"page","link":"https:\/\/documentation.crto.on.ca\/fr\/elements-of-documentation\/","title":{"rendered":"Elements Of Documentation"},"content":{"rendered":"

[et_pb_section fb_built=\u00a0\u00bb1″ inner_shadow=\u00a0\u00bbon\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ use_background_color_gradient=\u00a0\u00bbon\u00a0\u00bb background_color_gradient_start=\u00a0\u00bb#ffffff\u00a0\u00bb background_color_gradient_end=\u00a0\u00bbrgba(255,255,255,0.37)\u00a0\u00bb background_color_gradient_direction=\u00a0\u00bb90deg\u00a0\u00bb background_color_gradient_end_position=\u00a0\u00bb58%\u00a0\u00bb background_color_gradient_overlays_image=\u00a0\u00bbon\u00a0\u00bb background_image=\u00a0\u00bbhttps:\/\/documentation.crto.on.ca\/wp-content\/uploads\/sites\/11\/2021\/11\/CRTO-doc-elements.jpg\u00a0\u00bb custom_padding=\u00a0\u00bb50px||50px|\u00a0\u00bb border_width_bottom=\u00a0\u00bb3px\u00a0\u00bb border_color_bottom=\u00a0\u00bb#696bae\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_row _builder_version=\u00a0\u00bb3.25″ background_size=\u00a0\u00bbinitial\u00a0\u00bb background_position=\u00a0\u00bbtop_left\u00a0\u00bb background_repeat=\u00a0\u00bbrepeat\u00a0\u00bb custom_padding=\u00a0\u00bb120px||120px|\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb4_4″ _builder_version=\u00a0\u00bb3.25″ custom_padding=\u00a0\u00bb|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb custom_padding__hover=\u00a0\u00bb|||\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbSTANDARD TITLE\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ header_font=\u00a0\u00bb|||on|||||\u00a0\u00bb module_alignment=\u00a0\u00bbleft\u00a0\u00bb border_style=\u00a0\u00bbsolid\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

\u00c9l\u00e9ments constituant la documentation<\/strong><\/h1>\n

[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=\u00a0\u00bb1″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb background_image=\u00a0\u00bbhttps:\/\/documentation.crto.on.ca\/wp-content\/uploads\/sites\/11\/2021\/03\/crto-patternpurple-tall.jpg\u00a0\u00bb background_position=\u00a0\u00bbbottom_left\u00a0\u00bb custom_padding=\u00a0\u00bb70px||70px||true|false\u00a0\u00bb border_width_bottom=\u00a0\u00bb3px\u00a0\u00bb border_color_bottom=\u00a0\u00bb#696bae\u00a0\u00bb locked=\u00a0\u00bboff\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_row column_structure=\u00a0\u00bb1_3,2_3″ module_id=\u00a0\u00bbContentPersonalHealthRecord\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb1_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ header_font_size=\u00a0\u00bb45px\u00a0\u00bb custom_margin=\u00a0\u00bb||10px|\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

Contenu du dossier de sant\u00e9 personnel du patient ou client
\n<\/strong><\/h2>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=\u00a0\u00bb2_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance Expectations\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_padding=\u00a0\u00bb0px|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]\u00c0 moins d\u2019indications contraires dans d\u2019autres textes de loi, le dossier du patient ou client doit comprendre les \u00e9l\u00e9ments suivants :
\n[\/et_pb_text][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]Identification unique du patient ou client<\/span>, comme le nom et l\u2019adresse domiciliaire du patient ou client;
\n[\/et_pb_blurb][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]Nom du ou des m\u00e9decin(s) le(s) responsable(s) (MPR) ou de tout autre professionnel de la sant\u00e9<\/span>, comme le m\u00e9decin de premier recours;
\n[\/et_pb_blurb][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]Motif de la consultation<\/span>, s\u2019il y a lieu; et
\n[\/et_pb_blurb][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]Ant\u00e9c\u00e9dents cliniques pertinents du patient ou client<\/span> , comme la date et l\u2019heure de chaque contact avec le patient ou client.
\n[\/et_pb_blurb][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=\u00a0\u00bb1_3,2_3″ module_id=\u00a0\u00bbInaccurateDoc\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb1_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ header_font_size=\u00a0\u00bb45px\u00a0\u00bb custom_margin=\u00a0\u00bb||10px|\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

Documentation inexacte, incompl\u00e9t\u00e9 ou falsifi\u00e9e<\/strong><\/h2>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=\u00a0\u00bb2_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance Expectations\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_padding=\u00a0\u00bb0px|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]La documentation, ou le manque de documentation, joue souvent un r\u00f4le important dans les questions juridiques entourant les soins de sant\u00e9. Dans beaucoup de cas soumis Comit\u00e9 des enqu\u00eates, des plaintes et des rapports de l\u2019OTRO, on note que la documentation est souvent insuffisante pour refl\u00e9ter avec pr\u00e9cision le cours des \u00e9v\u00e9nements. Trop souvent, la consignation des \u00e9v\u00e9nements ou du r\u00f4le jou\u00e9 par le th\u00e9rapeute respiration est insuffisante ou inexistante.
\n[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=\u00a0\u00bb1″ _builder_version=\u00a0\u00bb4.8.2″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb background_color=\u00a0\u00bb#696BAE\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_row _builder_version=\u00a0\u00bb4.8.2″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb4_4″ _builder_version=\u00a0\u00bb4.8.2″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text _builder_version=\u00a0\u00bb4.8.2″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb background_layout=\u00a0\u00bbdark\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

VEUILLEZ PRENDRE NOTE…<\/strong><\/h3>\n

L\u2019OTRO a \u00e9t\u00e9 saisi de quelques cas o\u00f9 un th\u00e9rapeute respiratoire a intentionnellement falsifi\u00e9 le dossier de sant\u00e9 personnel d\u2019un patient ou client. C\u2019est une infraction tr\u00e8s grave et il est essentiel que les membres comprennent que ce qui suit constitue une faute professionnelle :<\/p>\n

La falsification d\u2019un dossier concernant ses responsabilit\u00e9s professionnelles.<\/em> (par. 16, Faute professionelle<\/span><\/em><\/a>, R\u00e8gl. de l’Ont. 753\/93)<\/span>.<\/p>\n

[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=\u00a0\u00bb1″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb background_image=\u00a0\u00bbhttps:\/\/documentation.crto.on.ca\/wp-content\/uploads\/sites\/11\/2021\/03\/crto-patternpurple-tall.jpg\u00a0\u00bb background_position=\u00a0\u00bbbottom_left\u00a0\u00bb custom_padding=\u00a0\u00bb70px||70px||true|false\u00a0\u00bb border_width_bottom=\u00a0\u00bb3px\u00a0\u00bb border_color_bottom=\u00a0\u00bb#696bae\u00a0\u00bb locked=\u00a0\u00bboff\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_row column_structure=\u00a0\u00bb1_3,2_3″ module_id=\u00a0\u00bbCorrections\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb1_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ header_font_size=\u00a0\u00bb45px\u00a0\u00bb custom_margin=\u00a0\u00bb||10px|\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

Corrections au dossier m\u00e9dical
\n<\/strong><\/h2>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=\u00a0\u00bb2_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance Expectations\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_padding=\u00a0\u00bb0px|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]S\u2019il est n\u00e9cessaire de corriger un dossier m\u00e9dical incomplet ou inexact, les th\u00e9rapeutes respiratoires doivent :
\n[\/et_pb_text][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]Conserver dans le dossier l\u2019information incorrecte, indiquer qu\u2019elle est incorrecte (p. ex., en la barrant) et s\u2019assurer que l\u2019information demeure lisible
\n[\/et_pb_blurb][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]Dater et mettre ses initiales sur les ajouts ou les corrections
\n[\/et_pb_blurb][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]Aviser tout travailleur de la sant\u00e9 qui pourrait \u00eatre touch\u00e9 par les renseignements inexacts
\n[\/et_pb_blurb][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=\u00a0\u00bb1_3,2_3″ module_id=\u00a0\u00bbDictation\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb1_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ header_font_size=\u00a0\u00bb45px\u00a0\u00bb custom_margin=\u00a0\u00bb||10px|\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

Dict\u00e9e<\/strong><\/h2>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=\u00a0\u00bb2_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance Expectations\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ custom_padding=\u00a0\u00bb0px|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]Dans certains cadres de travail, les th\u00e9rapeutes respiratoires doivent dicter leur rapport ou les entr\u00e9es au dossier. Il est important que les rapports g\u00e9n\u00e9r\u00e9s soient v\u00e9rifi\u00e9s par leur auteur, afin de veiller \u00e0 ce qu\u2019ils soient exacts. Nous incitons les th\u00e9rapeutes respiratoires de ne pas se contenter de dicter sans lire les rapports.
\n[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=\u00a0\u00bb1_3,2_3″ module_id=\u00a0\u00bbEHR\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb locked=\u00a0\u00bboff\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb1_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ header_font_size=\u00a0\u00bb45px\u00a0\u00bb custom_margin=\u00a0\u00bb||10px|\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

Les dossiers de sant\u00e9 \u00e9lecroniques (DSE)
\n<\/strong><\/h2>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=\u00a0\u00bb2_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance Expectations\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_padding=\u00a0\u00bb0px|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]Les dossiers de sant\u00e9 \u00e9lectroniques sont des versions \u00e9lectroniques des dossiers papier et sont donc assujettis \u00e0 la m\u00eame r\u00e8glementation et aux m\u00eames normes professionnelles que les dossiers papier
\n(Paterson, 2013). Les dossiers de sant\u00e9 \u00e9lectroniques diff\u00e8rent d\u2019une organisation \u00e0 l\u2019autre, mais ils pr\u00e9sentent des caract\u00e9ristiques communes :
\n[\/et_pb_text][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]identificateurs uniques (connexion et signature \u00e9lectronique);
\n[\/et_pb_blurb][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]piste d\u2019audit pour emp\u00eacher l\u2019alternance;
\n[\/et_pb_blurb][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]m\u00e9canismes assurant la protection de la vie priv\u00e9e et la confidentialit\u00e9;
\n[\/et_pb_blurb][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]syst\u00e8mes de sauvegarde et de stockage des renseignements sur la sant\u00e9; et
\n[\/et_pb_blurb][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]processus d\u2019\u00e9change et de transfert de renseignements.
\n[\/et_pb_blurb][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=\u00a0\u00bb1_3,2_3″ module_id=\u00a0\u00bbTemplates\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb1_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ header_font_size=\u00a0\u00bb45px\u00a0\u00bb background_color=\u00a0\u00bbRGBA(0,0,0,0)\u00a0\u00bb custom_margin=\u00a0\u00bb||10px|\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

Utilisation de mod\u00e8les
\n<\/strong><\/h2>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=\u00a0\u00bb2_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance Expectations\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ custom_padding=\u00a0\u00bb0px|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]L\u2019utilisation des mod\u00e8les de dossiers \u00e9lectroniques, tout particuli\u00e8rement ceux avec des champs d\u00e9j\u00e0 remplis, pose des risques aux dossiers exacts et complets. Pour r\u00e9pondre aux exigences en mati\u00e8re de documentation, les th\u00e9rapeutes respiratoires doivent s\u2019assurer que toutes les entr\u00e9es sont justes et compl\u00e8tes.
\n[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=\u00a0\u00bb1_3,2_3″ module_id=\u00a0\u00bbElectronicCommunication\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb locked=\u00a0\u00bboff\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb1_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ header_font_size=\u00a0\u00bb45px\u00a0\u00bb custom_margin=\u00a0\u00bb||10px|\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

Les communications \u00e9lectroniques
\n<\/strong><\/h2>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=\u00a0\u00bb2_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance Expectations\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ custom_padding=\u00a0\u00bb0px|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]Ce type de communication est devenu essentiel, \u00e9tant donn\u00e9 que les soins de sant\u00e9 sont de plus en plus progressifs et r\u00e9actifs. Le courriel, les messages textes et les soins virtuels par vid\u00e9oconf\u00e9rence et la t\u00e9l\u00e9m\u00e9decine sont consid\u00e9r\u00e9s comme des interactions avec les patients et clients. Par cons\u00e9quent, ce genre de contact doit \u00eatre document\u00e9 selon les m\u00eames principes et normes que les autres formes de documentation. Il est \u00e9galement important de documenter le mode de communication \u00e9lectronique (message texte, courriel). De plus, vous devez prendre des mesures pour veiller \u00e0 la s\u00fbret\u00e9 et \u00e0 la s\u00e9curit\u00e9 de ces renseignements confidentiels, comme ceux d\u00e9crits dans les Normes de pratique de l\u2019OTRO. Les th\u00e9rapeutes respiratoires doivent prot\u00e9ger contre le vol, la perte ou l\u2019utilisation ou la divulgation non autoris\u00e9e les renseignements personnels sur les patients ou clients (mots de passe, chiffrement, syst\u00e8mes de sauvegarde et d\u2019entreposage, processus de partage et de transfert d\u2019information).
\n[\/et_pb_text][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]En pr\u00e9servant la confidentialit\u00e9 de vos donn\u00e9es de connexion avec un mot de passe fort, et les modifiant p\u00e9riodiquement selon les modalit\u00e9s de la politique de votre employeur.
\n[\/et_pb_blurb][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]Fermeture de session lorsque l\u2019appareil n\u2019est pas utilis\u00e9
\n[\/et_pb_blurb][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]Utilisation d\u2019un identifiant au lieu de renseignements qui identifient les patients comme le nom, lorsqu\u2019on communique par voie \u00e9lectronique
\n[\/et_pb_blurb][et_pb_blurb use_icon=\u00a0\u00bbon\u00a0\u00bb font_icon=\u00a0\u00bb%%24%%\u00a0\u00bb icon_color=\u00a0\u00bb#696bae\u00a0\u00bb icon_placement=\u00a0\u00bbleft\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_margin=\u00a0\u00bb10px||10px||true|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb animation_style=\u00a0\u00bbzoom\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]En chiffrant les courriels et les autres documents contenant des renseignements de sant\u00e9 ou confidentiels avant de les transmettre.
\n[\/et_pb_blurb][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=\u00a0\u00bb1_3,2_3″ module_id=\u00a0\u00bbMedicalDirectivesRTProtocols\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb locked=\u00a0\u00bboff\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb1_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ header_font_size=\u00a0\u00bb45px\u00a0\u00bb custom_margin=\u00a0\u00bb||10px|\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

Ordonnances m\u00e9dicales et protocoles de th\u00e9rapie respiratoire
\n<\/strong><\/h2>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=\u00a0\u00bb2_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance Expectations\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ text_text_color=\u00a0\u00bb#000000″ background_color=\u00a0\u00bbRGBA(0,0,0,0)\u00a0\u00bb custom_padding=\u00a0\u00bb4px|||2px|false|false\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

Quand un th\u00e9rapeute respiratoire fournit des soins en vertu d\u2019une ordonnance m\u00e9dicale, il doit l\u2019indiquer dans le dossier de sant\u00e9 personnel du patient ou client et donner le nom et le num\u00e9ro de l\u2019ordonnance m\u00e9dicale (p. ex., ordonnance m\u00e9dicale de ventilation m\u00e9canique, no<\/sup><\/span> 00-001).<\/p>\n

Pour de plus amples renseignements, veuillez consulter les Lignes directrices de pratique Ordonnance de soins m\u00e9dicaux<\/a> de l\u2019OTRO.<\/p>\n

[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=\u00a0\u00bb1_3,2_3″ module_id=\u00a0\u00bbRetentionPersonalHealthRecords\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb locked=\u00a0\u00bboff\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb1_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ header_font_size=\u00a0\u00bb45px\u00a0\u00bb custom_margin=\u00a0\u00bb||10px|\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

Ordonnances m\u00e9dicales et protocoles de th\u00e9rapie respiratoire
\n<\/strong><\/h2>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=\u00a0\u00bb2_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance Expectations\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_padding=\u00a0\u00bb0px|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]Les membres travaillant dans un h\u00f4pital de l\u2019Ontario doivent savoir que la Loi sur les h\u00f4pitaux publics<\/em><\/strong> <\/a>stipule que les dossiers de sant\u00e9 des patients ou clients doivent \u00eatre conserv\u00e9s pendant au moins 10 ans \u00e0 compter de la derni\u00e8re consignation au dossier. De plus, les dossiers de sant\u00e9 des patients ou clients qui avaient moins de 18 ans au moment de la derni\u00e8re consignation doivent \u00eatre conserv\u00e9s au moins 10 ans \u00e0 partir du 18e anniversaire de naissance du patient ou client.<\/p>\n

Nous incitons les membres qui travaillent dans d\u2019autres \u00e9tablissements \u00e0 v\u00e9rifier les politiques de leur employeur relativement \u00e0 la conservation des dossiers et \u00e0 consulter la l\u00e9gislation \u00e0 ce sujet.
\n[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=\u00a0\u00bb1_3,2_3″ module_id=\u00a0\u00bbAbbreviations\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb locked=\u00a0\u00bboff\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb1_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ header_font_size=\u00a0\u00bb45px\u00a0\u00bb custom_margin=\u00a0\u00bb||10px|\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

Abr\u00e9viations
\n<\/strong><\/h2>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=\u00a0\u00bb2_3″ _builder_version=\u00a0\u00bb4.6.6″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbPerformance Expectations\u00a0\u00bb _builder_version=\u00a0\u00bb4.8.2″ custom_padding=\u00a0\u00bb0px|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]Pour \u00eatre compris, il faut utiliser des abr\u00e9viations normalis\u00e9es dans les dossiers et veiller \u00e0 la correction de l\u2019orthographe. On peut employer une abr\u00e9viation \u00e0 condition d\u2019avoir \u00e9crit au long le(s) mot(s) qu\u2019elle repr\u00e9sente lors de sa premi\u00e8re utilisation dans la note. Lorsqu\u2019on inscrit des nombres, on doit veiller \u00e0 pr\u00e9ciser l\u2019unit\u00e9 utilis\u00e9e afin d\u2019\u00e9viter toute erreur d\u2019interpr\u00e9tation. Quand il s\u2019agit de m\u00e9dicaments et de posologie, on doit toujours pr\u00e9ciser l\u2019unit\u00e9 apr\u00e8s chaque nombre.
\n[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=\u00a0\u00bb1″ _builder_version=\u00a0\u00bb4.8.2″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb background_color=\u00a0\u00bb#696BAE\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_row _builder_version=\u00a0\u00bb4.8.2″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb4_4″ _builder_version=\u00a0\u00bb4.8.2″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text _builder_version=\u00a0\u00bb4.8.2″ _module_preset=\u00a0\u00bbdefault\u00a0\u00bb background_layout=\u00a0\u00bbdark\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

VEUILLEZ PRENDRE NOTE…<\/strong><\/h3>\n

Comme les abr\u00e9viations peuvent varier d\u2019un \u00e9tablissement \u00e0 l\u2019autre, il vous incombe de v\u00e9rifier que les abr\u00e9viations employ\u00e9es sont accept\u00e9es dans l\u2019\u00e9tablissement o\u00f9 le document est utilis\u00e9.
\nL\u2019OTRO ne fournit pas de liste d\u2019abr\u00e9viations acceptables.<\/p>\n

[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=\u00a0\u00bb1″ _builder_version=\u00a0\u00bb4.8.2″ saved_tabs=\u00a0\u00bball\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_row column_structure=\u00a0\u00bb1_2,1_2″ _builder_version=\u00a0\u00bb4.6.6″ background_size=\u00a0\u00bbinitial\u00a0\u00bb background_position=\u00a0\u00bbtop_left\u00a0\u00bb background_repeat=\u00a0\u00bbrepeat\u00a0\u00bb animation_style=\u00a0\u00bbflip\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb1_2″ _builder_version=\u00a0\u00bb3.25″ custom_padding=\u00a0\u00bb|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb custom_padding__hover=\u00a0\u00bb|||\u00a0\u00bb][et_pb_toggle title=\u00a0\u00bbGlossaire\u00a0\u00bb admin_label=\u00a0\u00bbGLOSSARY\u00a0\u00bb _builder_version=\u00a0\u00bb4.11.3″ title_font=\u00a0\u00bb|||on|||||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n

Mandataires (des d\u00e9positaires des renseignements sur la sant\u00e9)<\/strong> d\u00e9finis par la Loi sur le <\/em>consentement aux soins de sant\u00e9<\/em> (LCSS<\/em>) par rapport au d\u00e9positaire de renseignements sur la sant\u00e9 comme suit : \u00ab …une personne qui, avec l\u2019autorisation du d\u00e9positaire, agit pour le d\u00e9positaire ou en<\/em> son nom en ce qui a trait aux renseignements de sant\u00e9 personnels aux fins du d\u00e9positaire… \u00bb<\/em><\/p>\n

Membre de l\u2019OTRO<\/strong> Un th\u00e9rapeute respiratoire inscrit aupr\u00e8s de l\u2019OTRO ; les cat\u00e9gories d\u2019inscription sont th\u00e9rapeute respiratoire dipl\u00f4m\u00e9 (GRT), th\u00e9rapeute respiratoire auxiliaire (PRT) et th\u00e9rapeute respiratoire inscrit (RRT).<\/p>\n

Dossier fond\u00e9 sur les exceptions<\/strong> M\u00e9thode de tenue de dossiers de sant\u00e9 des patients ou clients. Ce dossier n\u00e9cessite un plan d\u00e9taill\u00e9 sur les exceptions des soins ou un plan de soins standard et comprend des feuilles de soins, des dossiers graphiques et des notes sur les progr\u00e8s et peut prendre la forme d\u2019un plan d\u2019\u00e9valuation subjective\/objective (SOAP ou SOAPIE(R : donn\u00e9es Subjectives, Objectives, Appr\u00e9ciation, Plan, Intervention, \u00c9valuation, R\u00e9vision).<\/p>\n

Syst\u00e8me de consignation au dossier par probl\u00e8me<\/strong> Syst\u00e8me de consignation au dossier de sant\u00e9 comprenant des feuilles de soins, des listes de contr\u00f4le et des notes sur les progr\u00e8s prenant le format DARP (Donn\u00e9es, Action\/Analyse, R\u00e9ponse et Plan).<\/p>\n

D\u00e9positaire des renseignements sur la sant\u00e9 (DRS)<\/strong> D\u00e9fini dans dans la LPRPS comme s\u2019entendant \u00ab <\/em>\u2026 d\u2019une personne ou d\u2019une organisation vis\u00e9e \u00e0 l\u2019une des dispositions suivantes qui a la garde ou le <\/em>contr\u00f4le de renseignements personnels sur la sant\u00e9\u2026 \u00bb<\/em>.<\/p>\n

Directive m\u00e9dicale<\/strong> Ordonnance m\u00e9dicale touchant une gamme de patients ou clients qui r\u00e9pondent \u00e0 certaines conditions. La directive m\u00e9dicale est une ordonnance et doit donc r\u00e9pondre aux crit\u00e8res des ordonnances m\u00e9dicales valides.<\/p>\n

Note narrative<\/strong> Donn\u00e9es consign\u00e9es sous la forme de notes sur les progr\u00e8s compl\u00e9t\u00e9es par les feuilles de soins correspondant au plan de traitement.<\/p>\n

Dossier de sant\u00e9 personnel (DSP)<\/strong> Dossier tenu par les DRS qui dispensent des soins de sant\u00e9; sur support papier ou en format \u00e9lectronique.<\/p>\n

Soins primaires<\/strong> Comprennent, sans toutefois s\u2019y limiter, les \u00e9quipes de sant\u00e9 familiale, les centres de sant\u00e9 communautaire et divers organismes comme L\u2019Association canadienne pour la sant\u00e9 mentale.<\/p>\n

Dossier de sant\u00e9 bas\u00e9 sur l\u2019identification des probl\u00e8mes (en anglais, PoHR)<\/strong> Syst\u00e8me de dossier de sant\u00e9 comprenant un plan de traitement, une liste des probl\u00e8mes et des notes bas\u00e9es sur les progr\u00e8s, de m\u00eame qu\u2019une planification des cong\u00e9s pouvant prendre le format SOAP ou SOAPIE (donn\u00e9es Subjectives, Objectives, Appr\u00e9ciation, Plan, Intervention, \u00c9valuation).<\/p>\n

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    \n
  1. Cavoukian, A. (2009). Le Bureau du commissaire \u00e0 l\u2019information et \u00e0 la protection de la vie priv\u00e9e de l\u2019Ontario (2009). Circle of care: Sharing personal health information for healthcare purposes<\/em>. Extrait de : https:\/\/www.ipc.on.ca\/images\/Resources\/circle-care.pdf<\/a><\/li>\n
  2. Ordre des infirmi\u00e8res et infirmiers de l\u2019Ontario. (2008). Norme d\u2019exercice : La tenue de dossiers<\/em>. Extrait de : http:\/\/www.cno.org\/Global\/docs\/prac\/41001_documentation.pdf<\/a><\/li>\n
  3. Ordre des m\u00e9decins et chirurgiens de l\u2019Ontario (2012). Dossiers m\u00e9dicaux. \u00c9nonc\u00e9 de politique<\/em> (no 4 \u00e0 12). Extrait de : http:\/\/www.cpso.on.ca\/CPSO\/media\/uploadedfiles\/policies\/policies\/policyitems\/medical_records.pdf?ext=.pdf<\/a><\/li>\n
  4. Ordre des physioth\u00e9rapeutes de l\u2019Ontario. (2017). Norme sur la tenue de dossiers<\/em>. Extrait de : https:\/\/www.collegept.org\/rules-and-resources\/record-keeping<\/a><\/li>\n
  5. 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<\/em> 10, 18 (2011). https:\/\/doi.org\/10.1186\/1472-684X-10-18<\/a><\/li>\n
  6. Paterson, A. M. (2013). Medical Record as a Legal Document Part 2: Meeting the Standards. Journal of Legal Nurse Consulting, 24(1), 4-10<\/em>. Extrait de : http:\/\/www.aalnc.org\/?page=JLNC<\/a><\/li>\n<\/ol>\n

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