2.11.1 Maintains clear, accurate and comprehensive records of all patient/client encounters, recommendations, and plans to demonstrate professional accountability and to support continuity of patient/client care.

Has a unique patient/client identifier on every page of the patient/client health record.
Ensures records include signature and dates.

2.11.2 Records information, ensuring legibility, in either official language of Canada (English or French).

Produces health records in one of the official languages that can be read by another individual.

2.11.3 Prepares records and reports in a timely and systematic manner.

Produces a report within the stated timelines agreed upon with the patient/client.

2.11.4 Maintains and keeps updated equipment logs (calibration, safety inspections).

Produces equipment service records for an ultrasound machine.

2.11.5 Documents critical incidents and errors as a component of quality control and improvement

Uses reporting protocols and forms to record negative patient/client outcomes.

2.11.6 Documents the informed consent process and the patient’s/client’s understanding of the information provided, including if consent was obtained, refused or withdrawn.

Records the circumstances surrounding the patient’s/client’s consent and indicates his/her understanding of the information presented.

2.11.7 Documents involvement of and the patient’s/client’s consent to involve unregulated professionals and/or support personnel in the services provided.

Records the patient’s/client’s consent to involve unregulated health professionals in his/her care and
that he/she clearly understands the roles, responsibilities and the limitations of the service provided by the unregulated professional.

2.11.8 Documents information on all delegated controlled acts that one performs.

Documents who delegated the act, when, for which patient/client and the parameters of the delegation.

2.11.9 Documents assessment findings, including subjective and objective findings, the assessment method and type of assessment tools used.

Uses SOAP (subjective, objective, assessment, plan) notes to chart.

2.11.10 Ensures documentation is accurate and complete before applying his/her signature/attestation.

Reviews the notes and makes necessary changes to ensure accuracy and that accountability is properly documented prior to signing.