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16 Cards in this Set
- Front
- Back
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adequate patient record |
1. all info recorded -treatment neeeds -more info more serious -3rd person can recreate what u see did and why -permit continuity of care |
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good record helps in1 |
-minimize mishaps -admissible in evidence -use to testify -reflect credibility -important in counselling due to no physical evidence |
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penal consequences |
federal criminal law and provincial laws : statutory obligation |
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professional consequences |
fail in professional misconduct |
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guidelines |
-honest -objective professional tone -chronological -sign and date and initial -only relevant -sensitive info recorded -made by person providing the service -if made by 3rd party, verified by person who did it. |
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falsifying records result in |
criminal code offense |
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Quagmire, 3 sets of legal record keeping, confidentiality, disclosure and patient access principles |
1. common law: civilly liable 2. professional obligation to a regulatory collage or body: suspended licence 3. federal and provincial statues about record keeping: prosecution |
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Ontario Freedom of information Legislation includes |
1. MFIPPA 2. FIPPA |
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FIPPA and MEIPPA |
all prov. municipally created government agencies two functions 1. provide individuals right to access 2. prevent government to collect and disclose -only apply to public settings |
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PHIPA |
all info by HIC: all health professionals and institutions -many agencies adopt PHIPA as a policy -only collect/use/disclose under consent or lawful purpose |
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QCIPA |
permit disclosure of info to "quality of care committee" limits access to such info and make it inadmissible in any provincial proceedings |
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PIPEDA |
collection, use and disclosure of info in the course of commercial activities -comparable to PHIPA but not QCIPA |
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ownership |
owned by practioner or employer -patient has right to access |
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administrative record |
owned by agency created them, patient has no right to look unless required by court or statute |
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record retention policies |
-remain for 10 years if 18 to 28
-statue of limitation only begin when the wrong was realized -relating to tax, finicial purposes can be relevant to keep longer -more important in young, risk patients |
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Computer/Electronic Records Statements of Opinion Private Records Recording Information about a Third Party or from aThird Party E-mail Communication |
yep. |
