PrintImprimer We all know that record-keeping is an important part of good client care. But, record keeping can sometimes feel like it’s too time consuming and tedious, taking away from other "pressing" work such as client care or meetings. Here are three reasons why good record keeping habits are an integral part of effective client care. 

1. Good Records Capture Day-To-Day Client Care

 Record keeping helps dietitians track their day-to-day practices. In clinical settings, it allows them to review the reasons for treatment, the details of a treatment plan, the progress of clients and the discharge plan. Having accurate and current client information at your fingertips can help you save time and be more effective in caring for clients safely.

2. Optimizes Interprofessional Collaboration

 Good record keeping optimizes interprofessional collaboration. It provides a means for sharing client health information within the circle of care to avoid unnecessary duplication and ensure continuity of care. Well maintained health records facilitate and enhance the coordination of services to optimize safe and efficient client care.

3. Provides Accurate and Timely Information to Clients

Clients have the right to access the information contained in their health records within a reasonable period of time. They may need the information for matters related to other health care providers, for a disability or an insurance claim. Providing accurate and timely information to clients will be more likely if your records are complete and current at all times.

Failing to keep accurate records and failing to provide reports or information to clients upon request, is considered professional misconduct, according to the Dietetics Act, 1991, Ontario Regulation 680/93, Professional Misconduct,

“22. Failing to keep records as required.
24. Failing, without reasonable cause, to provide a report or certificate relating to an assessment or treatment performed by the member, within a reasonable time after a client or his or her authorized representative has requested such a report or certificate.”

Set Goals for Improvement

Use your annual Self-Directed Learning Tool to help you set and achieve goals for improving your record keeping practices. Reflect on the content of your client records and on how you keep records. Ask yourself: Is your documentation complete and accurate? Are your notations timely and legible? Are they helpful to your health care team? Do your record keeping practices reflect legal requirements and your employer obligations?
 
You will find that charting can be done quite efficiently with good record keeping habits and a sound knowledge of record keeping systems. A dietitian’s knowledge, skills and judgment are reflected in good record keeping habits. Good documentation demonstrates a dietitian’s accountability and commitment to safe, effective and ethical dietetic services.