Record Keeping FAQs

Check out the Record Keeping frequently asked questions and videos.

FAQs: Record Keeping—Clinical Records

  • Can I include information collected by another health professional (for example, assessment findings)?

  • Why do I need to include advice or information provided by telephone or email?

  • What other reports or communication should be included?

  • What if a patient asks me to not include something?

  • Is an analysis statement, clinical impression or diagnosis required?

  • Do patient goals and outcomes need to be documented in the chart?

  • How much detail should be included when documenting treatment?

  • What information should be included in a discharge summary or end of care note?

  • How often should an entry be made in the clinical record?

  • Why do I have to document missed or cancelled appointments?

  • Why do I have to document that consent was obtained?

  • How often do I need to chart?

FAQs: Record Keeping—Confidentiality and Access

  • What should I do if a patient or someone else wants access to a record?

  • Who should have access to the records?

  • What steps should I take to ensure confidentiality?

  • Can the patient ask to have their record changed?

  • Help! I lost a patient record...what should I do? What are my professional obligations?

  • What if someone other than a patient or their representative wants access to a chart?

  • When is express consent needed for release of personal health information?

  • When can you rely on implied consent?

  • Are there any circumstances when you can release personal health information without consent?

  • Do I need written consent to disclose personal health information?

  • What if a patient asks me to not record certain information? (The concept of a lock box.)

  • What are the steps to take in the event of a privacy breach or lost file?

  • What to do with patient records when retiring, selling, or leaving a practice?

  • Who is the Health Information Custodian (HIC) in a group practice?

  • Can I store patient records in the cloud?

  • Can I use email to communicate with patients?

  • Do I need explicit consent to share information with a patient’s family doctor?

  • A PT employee accessed the wrong patient file but it was a one-off error. Do I as the clinic owner and the health information custodian (HIC) need to report the patient information breach?

FAQs: Record Keeping—Financial Records

FAQs: Record Keeping—General

  • What is a Health Information Custodian (HIC)?

  • Why is it important to identify the Health Information Custodian (HIC) in the patient record?

  • I work in an interprofessional team. What should we consider if we keep joint or combined records?

  • What should I consider when creating, storing and transmitting electronic information?

  • Why should I audit my records? How often should I audit?

  • What should I consider when using abbreviations, care maps, exercise flow sheets, charting by exception or other time-saving documentation tools?

  • What does it mean to be able to uniquely identify individuals?

  • Do I need to sign my full name and title every time I make an entry?

  • What should I consider when using an electronic signature or signature stamp?

  • What information should be documented about the care assigned to physiotherapist assistants?

  • What information should physiotherapist assistant document? Do I need to co-sign entries?

  • How should I correct errors or make changes to an entry?

  • I am retiring or changing jobs; what should I do with the patient records?

  • Should I audit my records?

  • What is a lock box?

  • How should I reference documents that are not part of the patient record?

  • My patient has asked for a copy of their patient record. How much can I charge for providing a photocopy?

  • What information should be included in a discharge summary or end of care note?

  • How should my title appear on a business card or correspondence?

FAQs: Record Keeping—Storage, Retention and Disposal of Records

  • Can the clinical record be a combination of paper and electronic data?

  • If a record is converted from paper to an electronic format does the original paper copy need to be kept?

  • What should I consider when storing the record in a patient’s home or other facility?

  • Can portions of the record be kept separately?

  • How should records be stored when they are no longer active?

  • How long should records be kept?

  • How should I dispose of records?

  • What are the obligations of the Health Information Custodian (HIC) when a patient file is lost or stolen?

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