Law 3101A/B Chapter Notes - Chapter 9: Canadian Medical Association, Medical Record, Personal Information Protection And Electronic Documents Act
Document Summary
All information about treatment, counselling, care need to be recorded. Need to contain all information necessary to carryout treatment. Level of detail is based on seriousness of the problem, & physician"s assessment. The record must have enough details to be able to provide continuity of care. b. If record is su cient to satisfy clinical needs, it is adequate for legal purposes physicians shouldn"t keep records for the law, it should be for patient"s sake. Guidelines for record keeping: written in objective, professional, non sarcastic tones, placed in chronological (time) order. : alterations are allowed, but original entry must be left intact & legible, any corrections made must be initialed & dated, author need to print & sign the record, as well as indicate his position unless only. Tuesday, november 6, 2018 one physician is involved: made in dark ink and legible. 7. records must be complete to avoid wrong interpretations: only relevant treatment information on record.
