Law 3101A/B Lecture Notes - Lecture 9: Ontario Provincial Police, Vancouver Coastal Health, District Health Board
11 Dec 2016
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The record includes all clinical information about a patient, howsoever recorded. The driving force in record keeping is not the law, but rather the patient"s clinical needs (at a minimum) (i. e. a record allows for ongoing, quality care will be adequate for legal purposes). Record: must contain all treatment, counsel, and care of a patient, regardless of the form it is recorded in (e. g. electronic, paper) a patient has all the right to access their record. The record should permit a third person to recreate what you saw, heard, did, and why you did it. If another professional were to take the file, they should be able to continue the quality of care for the patient (allow continuity of care), without detriment to the patient. A record must pertain to the author"s views. (b) legal importance of record keeping policies and practices.
