Law 3101A/B Lecture Notes - Lecture 9: Microform, Tuberculous Meningitis, Personal Information Protection And Electronic Documents Act
Counselling, or care for seeing a highly manipulative, rash, immature patient. Record for an older, stable long time patient is less detailed than the record. The level of detail should increase with: seriousness of the problem, risks of treatment, novelty of the treatment, and challenging character of the patient. The record includes all recorded clinical information about a patient treatment, Doesn"t matter how it"s recorded written by hand, computer, videotape, audiotape. Driving force in record keeping is not the law, but rather the patient"s treatment needs record that provides for ongoing quality care will be good for legal purposes. Should include more information at the outset patient history, etc. ; more quality care and the problem doesn"t arise in the first place. The record should permit a third person to recreate what you saw, heard, did, and why you did it, as well as permit continuity of care. Legal importance of record keeping policies and practices.