Record KeepingPractice Scenarios & Quizzes

Record Keeping
Practice Scenarios & Quizzes

August 2019
   

1. Joint Records

You work as a dietitian in a public health unit and participate in a prenatal nutrition program for high-risk expectant mothers. The program is operated by an independent community agency and the clients are those of the agency, not the public health unit. Your notations are kept only in a record on the premises of the agency. You know that the agency does not follow the College's expectations for chart security and retention. Are you at risk for this record keeping approach?

Dietitians often work in settings where they are expected to use a joint record, because this makes practical and clinical sense for a team practice. However, this places some obligation on the dietitian to ensure that the record keeping practices of the facility, employer or team are consistent with the expectations of the College and the dietetic profession. Professionals in public facilities such as hospitals, government departments or settings where only health practitioners work are more likely to share values and approaches. Even in these situations, dietitians should check record keeping practices to ensure their quality.

Where the employer, facility or program is privately operated, the dietitian may need to exercise a higher degree of scrutiny of the record keeping practices. In this scenario, the records are partially those of the dietitian, so he or she has to ensure that the facility meets minimal professional expectations. Usually this can be achieved by communication between the parties. Refer to the Professional Practice Standards for Record Keeping for the minimal expectations that dietitians must meet in their dietetic practice when keeping records.

Where the facility, employer or program does not meet the record keeping expectations of the dietetic profession, the dietitian must advocate for a change to the practices or, failing to reach compliance with the College's regulation, may need to keep separate records. This should not be done secretly (see Keeping Private Records Scenario).

It is important to resolve record keeping issues when starting a position. If a dietitian is in an employment situation where they have record keeping issues, it’s important to resolve them immediately. Once a relationship ends or a dispute arises, it may be more difficult to resolve them. In some private practices, the employment or partnership agreement should indicate who is the health information custodian and if the dietitian is an agent, how they may obtain necessary access to records. If the health information custodian is not a dietitian, there should be explicit agreement to comply with the College's expectations and the Personal Health Information Protection Act, 2004. 

2. Keeping Private Records

You work at a facility with other health professions. The facility has an approved form that it expects all members of the health care team to follow. You place the traditional information (medical history, major findings from assessment, treatment plan) on the approved form. However, there is not an appropriate space to put your detailed meal plan calculations and energy intake notes; these entries are rough and messy, and you would be embarrassed to put them in the main chart. They would be of no use to anyone but you. Can you keep those notations in a separate file that you keep as long as you are seeing the client and then discard?

The temptation by practitioners to keep their own records separate from a central record keeping system is illustrated in this scenario. This practice is not recommended. The difficulty is that keeping private records prevents the facility or organization from meeting its own record keeping obligations (e.g. maintaining security, providing access to clients, and destroying the record in accordance with an established retention policy).

Private records consist of entries that are not included in the official chart of the facility or employer for whom a dietitian works. Unlike rough notes, which can be destroyed after they have been completely transcribed onto the official chart, these records are typically maintained by a dietitian for some time for private use. There are a number of reasons why a dietitian might wish to keep a private record:

  • The official chart requires a form that does not lend itself to recording all of the information the dietitian wishes to record;
  • The employer or facility discourages the extensive recording of information that the dietitian wishes to do or that is required by the College;
  • The official record is inconvenient to access, because of the procedures, the length of time it takes to retrieve the record, or because others are often using it;
  • The dietitian believes that the information handling policies of the facility or employers do not permit compliance with College regulations or other legal requirements (e.g. providing adequate access to clients);
  • A dietitian's private record tends to be messy and not in a form that is useful or appropriate for others on the health care team to see;
  • On rare occasions, the dietitian may be concerned about the lack of privacy afforded to the official record (e.g., where very private information is revealed that a client does not want the entire team to know, or where the employer or facility is privately owned and does not respect confidentiality) or
  • The dietitian is concerned that a copy of or access to the official record will not be given when leaving the facility or the job.

However, serious problems can arise when a dietitian maintains private records without the knowledge and authority of the facility or employer:

  • It is difficult for the information policies of the facility or employer to apply to a dietitian's private record (e.g., it might not be kept with the same degree of security as the official record);
  • Valuable information may be inaccessible to the rest of the health care team; and
  • The legal obligations of the facility or employer cannot be fulfilled. If a client wishes to exercise his or her right to see the entire file, the facility or employer cannot provide this access where it has no knowledge of the dietitian's private record. Or if the entire chart is required to be produced in a legal proceeding, the private record will not be included, placing the facility or employer in contravention of the law.

Some solutions to these competing considerations include:

  • Do not keep private records. Record everything that needs to be recorded in the official chart.
  • Advise the facility or employer that you are keeping private records and negotiate appropriate policies and procedures respecting them, such as access by others, security and ability to remove private records when leaving, etc.
  • Discuss with the facility or employer the reasons for keeping private records in the first place, so that any underlying issues are appropriately addressed.

3. Email Communication

You work in public health and communicate with a lot of clients by email. Some of those emails deal with individual health concerns (in some cases, concerns about third parties) and with sensitive matters (e.g. sexually transmitted diseases). What considerations arise here?

As a general rule, it is not acceptable to send personal health information through regular email. Acceptable options include obtaining the person's consent to use email, encrypt the email, or make the information anonymous. Sometimes consent can be inferred by the fact that the person has initiated the communication by email, or has asked the dietitian to respond by email.
However, the dietitian should ensure that the consent was informed, in that the recipient knows the sensitivity of the type of information that will be contained in the email. Also, keep in mind that the consent of the recipient does not apply to any third person discussed.

Retention of the email is another important issue. If the information in the email must be noted in the client file, for instance, a recommendation for a diet order, then a copy of the email must be kept on file. For example, if the client has follow-up questions or challenges your advice, having a copy of the email is important.

Record Keeping - Quiz

Select the best answer to each of the following questions. Consider the reason for your choice. Review the correct responses. 

1. In the scenario "Joint Records", is the record keeping system adequate?

a.  No, because the records are not kept in accordance with College and professional expectations
b.  No, because the people who control the record are not regulated health professionals
c.  Yes, because the person served is a client of the organization, not the dietitian
d.  Yes, because the record is maintained according to the criteria of the dietitian's employing agency
 
The best answer is (a). These are health care records and they should be created and maintained according to professional expectations.  

Answer (b) assumes that no appropriate record keeping safeguards can be established where non-regulated persons control them. While clearly it is more difficult to ensure that adequate safeguards are in place for unregulated custodians, it is not impossible. Answer (c) fails to recognize that even if the person is primarily the client of the organization, the person is also a client of the dietitian. Answer (d) inadequately reflects the independent professional obligation on the dietitian to ensure that appropriate records are kept. While there is some consideration of the organization's criteria, the dietitian has a responsibility to ensure that the records are kept appropriately.

2. In the scenario "Joint Records", what should you do?

a.  Keep your own records separate and apart from the agency's chart
b.  Make your entries on the agency's chart but keep a copy for yourself
c.  Discuss with the agency if it will change its record keeping practices to meet the College's and professional expectations
d.  Explain the situation to the client and obtain his or her consent to follow the agency's record keeping practices
 
The best answer is (c). It addresses the issue in a consultative and collegial fashion and could provide the best solution.

Answer (a) may work as a last resort, but requires that you advise the agency of your intent and deprives the others using the chart at the agency from access to your records. Answer (b) only addresses the retention and client access issues. It does not address concerns such as the security and confidentiality of the agency's copy of the record. Answer (d) is not preferred because it likely involves your discrediting the agency you work with. In addition, obtaining client consent to compromise professional standards is never the best solution.

3. In the scenario "Keeping Private Records", should you keep separate records and then discard this additional information?

a.  Yes, as no one else needs this additional information
b.  Yes, so long as you get the permission of your facility and do not discard the information for 10 years
c.  Yes, as the official chart contains the minimal information expected by the College
d.  No, private records are too dangerous to keep
 
The best answer is (b). If the facility agrees to your keeping these separate records and makes appropriate references to them in its record keeping practices, then most of the problems are solved. However, this answer places a burden on you to secure and organize the records appropriately.

Answer (a) misses the point. Even if the others on the team could never want access to the record, other issues need to be dealt with, such as security, confidentiality and access should clients approach the facility for their "complete" record, etc. Answer (c) similarly misses the point. A record, once made, must be treated accordingly. The fact that the official facility chart meets your minimal obligations does not detract from the fact that an additional private record was made. As such, your private record must be linked to the official chart and retained for 10 years. Answer (d) however, implies that the record is filed with the official record and is a possible solution. The reason answer (b) is preferred is because it is more transparent and collegial.

4. Which of the following is not a reasonable security measure for client health records?

a.  Written policies and procedures
b.  Records will never leave the facility
c.  All staff sign a confidentiality agreement
d.  Access to records is on a need-to-know basis
 
The best answer is (b). It may be necessary to remove a record from a facility for some purposes (e.g. a home visit or to testify at a hearing). Thus, it is better to have appropriate measures for such eventualities than to try to prohibit them entirely. All of the other answers should be part of a security program for client records.

5. Client records should be retained for how long?

a. 10 years from each visit that the client fully completed
b. 10 years from the last assessment date
c. 10 years from the last visit or 10 years after the date the client turns or would have turned 18 years of age
d. 5 years for most diagnostic imaging records
 
The best answer is (c). This reflects the College’s Professional Practice Standards for Record Keeping. Answer (a) misses that the triggering event is the last client visit.  Answer (b) misses the special provision dealing with clients who are minors. Answer (d) focuses on a minor point. Where other statutes apply, those provisions take precedence. However, it would be rare for the dietitian to have such a record in their chart.