The Importance of Good Record Keeping
Posted On: March 15, 2022
Maintaining good patient records is a fundamental part of a Naturopathic Doctor’s duty when providing patient care. The importance of keeping comprehensive patient records cannot be emphasized enough. When it comes to health records, documenting more information rather than less is not only in the best interest of the patient, but also the ND’s.
Poor record keeping practices are not uncommon, however, and can impact the quality of an ND’s patient records and subsequent patient care.
Some poor practices include:
- Relying on templates in an electronic medical records system.
- Completing a patient chart days after a patient’s appointment.
- Modifying a patient’s record without tracking changes or initialing.
- Using illegible or uncommon short forms or abbreviations.
Practices like these can impact the quality of a ND’s patient record, which in turn affect the patient and the healthcare they receive. The College expects that NDs assess their record keeping practices regularly and implement better practices.
Record Keeping for the Patient’s Benefit
It’s essential that NDs recognize their responsibility to their patients when it comes to their record keeping practices. Patients trust their ND to not only provide them with competent care, but to also keep a detailed record of the care they are providing. As a regulated health professional, it’s the ND’s responsibility to maintain thorough patient records and are meeting the standards of the profession. NDs should ensure that each patient record is comprehensive and accurate so that the record provides a clear depiction of the care delivered by the ND and received by the patient.
A best practice approach to maintaining a comprehensive patient record is documenting all aspects of a patient visit during, or immediately following the appointment to ensure accuracy of the records. Additionally, any other communication outside appointments should be retained by the ND and added to the patient’s record (including but not limited to emails, test results or phone conversations). Failing to complete a patient record within a reasonable time following the interaction with the patient can result in incomplete documentation resulting in a poor patient record.
Upon completing a patient chart, an ND should review their notes to ensure all information has been recorded and a clear account of the patient’s health and their reasons for treatment has been documented.
Record Keeping for the ND’s Benefit
An ND’s patient records are a testimony to the quality of care they deliver and the proficiency of their practice. For this reason, patient records are typically included in the evidence relied upon by the Inquiries, Complaints and Reports Committee (ICRC) when investigating complaints about patient care. Patient records are expected to provide a clear picture of the patient care the ND delivered and whether the ND is acting in accordance with the College’s standards of practice.
If an ND has complied with the Standard of Practice for Record Keeping, the College and other healthcare professionals should be able to understand the ND’s clinical judgement and the naturopathic care provided to the patient.
It’s important to note that if an ND fails to document something in the patient file, it can be assumed that whatever wasn’t documented didn’t happen. Take for example the ongoing discussion of consent with a patient. An ND may claim to have obtained consent from a patient through a verbal discussion for a treatment, however, did not record the discussion in the patient’s chart. If the College or another person where to review the patient’s record, there would be no way to confirm that consent was ever obtained from the patient. It could therefore be determined that the ND failed to obtain consent.
It is always the ND’s responsibility to maintain their patient records in accordance with the standards of practice. Failing to do so can put patients at risk, put into question an ND’s understanding of the regulations, legislation and standards of practice, and contribute towards creating a negative perception of the profession. To ensure compliance and best practices, NDs should regularly review their records and the standards of practice to ensure they are implementing good practices and are meeting their professional obligations.