You Asked About… Record Keeping

Jul 16, 2020 | Blog, News, Your Questions Answered

Q: What are the College’s record keeping requirements?

CDBC Bylaws section 70 outlines a registrant’s obligations for record keeping. Maintaining records is addressed in greater detail in the CDBC Standards of Practice, Standard 15: A Dietitian maintains clear and accurate records that document communications and the provision of professional services and in the CDBC Standards for Record Keeping.

Q: Sometimes I feel that I am the only one reading my documentation. Why is it important to have standards in place if I am simply documenting for myself?

Documentation is important, not just because it is a legal aspect of practice. Accurate, complete, and timely record keeping minimizes risk of care delays, practice errors and omissions, and reduces potential professional boundaries and discrimination issues, while fostering inclusive, client-centered care. It is important to consider that while it may seem that you are the only one reading your documentation, your clients and others have the right to request access to your records at any time.

The Standards for Record Keeping were developed with protection of the public in mind, providing expectations for Dietitians to clearly communicate the assessment of their client’s needs, the goals of the nutrition care plan, the outcome, and the evaluation/adjustment of those actions. Documentation facilitates continuity of care and discharge planning while being an important support during periods of unexpected absence of the regular dietitian where another dietitian may cover their work.

From a College perspective, appropriate documentation fulfills the regulatory mandate of public protection, by informing the public, employers, health profession colleagues and the College about the expectations that dietitians must meet for record keeping. In some cases, documentation can be helpful and even essential when considering College programs such as maintenance of the Quality Assurance Program, Inquiry and Discipline Committees’ activities.

It is also important to consider that individuals outside of the health care system can request access to health records, in accordance with privacy laws. This includes regulatory colleges, lawyers, and law enforcement employees. Members of the public (client and/or family members) may also request access to their own records, as allowed under the Freedom of Information and Protection of Privacy Act (FIPPA – for public employees), Personal Information Protection Act (PIPA- for private employees), and Personal Information Protection and Electronic Documents Act (PIPEDA – those working cross-jurisdictionally within Canada or for federal agencies). In a hospital setting, medical records are retained for a minimum of 16 years and in the private setting, for a minimum of one year. During this time, should a client or member of the legal community request access to the medical record, your documentation is accessible.

 

Q: I understand that I am not permitted to maintain a duplicate record or “ghost chart”. Why not?

A ghost chart can be defined as a duplicate or second health record held separately from a client’s main record, containing personal identifiers and/or medical information, including but not limited to assessment forms, food records, nutrition care plan and follow-up notes, that otherwise belong in the medical record or shouldn’t be kept.

Per the CDBC Standards of Record Keeping, specifically Standard 5e: “Dietitians ensure reasonable measures are in place to maintain the security of client health records. A dietitian demonstrates the standard by ensuring the following: … There is no separate parallel client record (ghost chart) kept by the RD.”

Additionally, a “ghost chart”, puts a dietitian at risk of violating Standard 2: “Dietitians document in a systematic and timely manner. A dietitian demonstrates the standard by ensuring the documentation:

  1. a) Is completed by the RD, except during shared appointments whereby another provider documents dietitian services that were provided which are then verified and signed by the RD.
  2. b) Is completed diligently, at the earliest possible opportunity following the client interaction/dietetic services to prevent any delay in care or service.
  3. c) Includes the date the entry was made and the date that the interaction/dietetic services occurred, if documentation occurs after the date of interaction/service.
  4. d) Is chronological.
  5. e) Is organized to facilitate timely retrieval and use of the information

Best client care cannot be achieved if timely entries into the client health record are not made. Documenting as soon as possible into your client record is tantamount to provision of good care.

There is growing jurisprudence around issues pertaining to ghost charts where key information is omitted in the main chart by being kept in the ghost record, and potentially lost if the ghost record is destroyed without transfer of information in to the main record. Ghost records are also often not secure when held in a shared office where there is a risk of confidential information being accessed by unauthorized personnel. These types of situations are subject to disciplinary actions, as they are not consistent with College Standards and the public interest.

 

Q: What happens if I must travel remotely for work between workplaces or between clients and my workplace? Does this mean that I cannot carry any client information with me?

In the instance where you have a job requiring travel between your clinic and your clients, you may choose to transport temporary documents. Preferably, the documents are electronic and the “collection, use, storage, disclosure, transmission, and disposal of personal health information maintains the client’s privacy and confidentiality (e.g. through the use of physical controls, passwords and/or encryption, as applicable.” As discussed in the Interpretive Guideline of the Privacy Legislation for Private Practitioners, in the case of paper copies of personal information, “keep all records containing personal information safe from public view and from access by other clients.” Additionally, “limit use, disclosure and retention –use personal information and disclose it to another person only for the purpose it was collected; keep personal information only as long as needed.” Finally, “keep information only as long as needed for the purpose stated or as required by law.” Once you have documented in the health record at your clinic, you must securely destroy any temporary paper or electronic documents that you held containing private information about your clients.

 

Q: I am unsure if I need to document.

The CDBC bylaws and Standards for Record Keeping set out expectations in clinical and non-clinical work settings. If you have questions about the requirement for documentation in your specific area of dietetics, please contact the CDBC. The College will provide an answer that addresses  the context and intent of your program and how it may impact the client/audience receiving your services.

Example 1: I am providing nutrition information in a group or individual setting such as a grocery tour, general nutrition labelling or visiting a school classroom to teach children about healthy eating. 

You are not required to document this as you are not fostering a therapeutic client relationship, nor are you providing information that is (1) outside of what could easily be found online or in-person, and (2) specific to a disease process or therapeutic nutrition.

In private practice, you are required, under section 74 of the Marketing bylaws, to retain for one year after the date of publication, hard copies or electronic publications shared with your clients to promote your services. You are also expected to maintain financial records when billing occurs for your services (Standard 4, CDBC Standards for Record Keeping).

Example 2: I am being asked questions that are specific to a disease process or specific to a client who attended a program that otherwise provides general nutrition information.

You are required to document your interactions for clients with whom you are (1) practicing dietetics (providing specific medical nutrition therapy) and (2) developed a therapeutic practitioner-client relationship.

Example 3: I am developing/revising menus at a facility where I am employed.

Outside of your workplace requirements, you are not required to document additional information. The menus represent the documentation illustrating your work.

 

 

 

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