Information that is legally significant.
WHAT RECORDS MUST DO
Support clinical care Evidence what was done Meet retention requirements Remain confidential
WHY THEY ARE LEGALLY SIGNIFICANT
They are the evidence in any complaint, claim or investigation.
WHAT A RECORD SHOULD CONTAIN
Patient identification Date of each encounter What was found, done and advised Who provided the care Consent, where relevant
WHAT MAKES RECORDS DEFENSIBLE
Contemporaneous Legible Signed or attributable Unaltered
WHY CONTEMPORANEOUS
Entries made later are given less weight and may be challenged.
WHAT TO NEVER DO
Alter a record after the fact Remove entries Backdate
WHAT TO DO ABOUT A CORRECTION
Add a dated correction, leaving the original visible.
WHAT CONFIDENTIALITY REQUIRES
Access limited to those providing care Records not discussed where others can hear Physical records secured Electronic records access-controlled
WHY IT MATTERS ACUTELY HERE
Health information is among the most sensitive categories, and breaches cause real harm.
WHAT TO ESTABLISH
Who may access what How access is logged
WHAT TO TRAIN STAFF ON
That discussing patients outside care is a breach.
WHAT RETENTION APPLIES
Per the requirements of the regulator and applicable law.
WHAT TO ESTABLISH
The period, for each record type.
WHAT TO DO ABOUT REQUESTS FROM PATIENTS
Provide access, per the applicable rules.
WHAT TO DO ABOUT REQUESTS FROM OTHERS
Establish authority before disclosing anything.
