Law 3101A/B Lecture Notes - Lecture 10: Vancouver Coastal Health, District Health Board, Regulatory College
The record includes all recorded clinical information about a patient. The driving force in record keeping is not the law, but rather the patient"s treatment needs (i. e. a record that provides for ongoing quality care will be sufficient for legal purposes). The level of detail should increase with the; seriousness of the problem; risks of treatment; novelty of the treatment; and challenging character of the patient. The record should permit a third person to recreate what you saw, heard, did, and why you did it. The record should permit continuity of care. Calls them as you see them, to the best of your ability . There are no forbidden words, there are no mandatory words. It is much simpler than people think. Purpose of records not the law, but the needs of the patient. Term patient record includes any information recorded about the patients treatment counseling or care will be considered a part of the patients records.