Effective September 2015

Standard

A regulated member of ACSLPA prepares and maintains clear, accurate, timely and complete records to document the delivery of professional services.

Indicators

To demonstrate this standard, the regulated member will:

 a) Practice in compliance with employer policies, contractual agreement requirements, applicable legislation and key 5 ACSLPA documents regarding documentation.

 b) Practice in compliance with employer policies, contractual agreement requirements, applicable legislation and key ACSLPA documents regarding management
………of information (e.g., retention, transfer, disposal).


5 Includes: Code of Ethics, Standards of Practice, Position Statements, Guidelines and Protocols.

Expected Outcomes

Clients can expect that processes are followed to ensure the appropriate preparation, maintenance and disposal of records.

Resources

All ACSLPA documents and relevant Alberta Government legislation can be accessed from the ACSLPA website at www.acslpa.ca.

  • ACSLPA. (2017). Code of Ethics. Edmonton: Author.
  • ACSLPA. (2011). Clinical Documentation and Record Keeping Guideline. Edmonton: Author.
  • CAASPR. (2018). Practice Competencies for Audiologists in Canada. Ottawa: Author.
  • CAASPR. (2018). Practice Competencies for Speech-Language Pathologists in Canada. Ottawa: Author.
  • Government of Alberta. (2000). Freedom of Information and Protection of Privacy Act (FOIP). Edmonton: Alberta Queen’s Printer.
  • Government of Alberta. (2000). Health Information Act. Edmonton: Alberta Queen’s Printer.
  • Government of Alberta. (2000). Health Professions Act. Edmonton: Alberta Queen’s Printer.
  • Government of Alberta. (2003). Personal Information Protection Act (PIPA). Edmonton: Alberta Queen’s Printer.
  • Government of Alberta. (2013). Alberta Netcare Electronic Health Record Information. Edmonton: Alberta Queen’s Printer.

Glossary

Client refers to “an individual, family, substitute decision maker, group, agency, government, employer, employee, business, organization or community who is the direct or indirect recipient(s) of the regulated member’s expertise”.

Professional services refer to “all actions and activities of a regulated member in the context of professional practice”.

Record refers to “information in any form or medium, including notes, images, audiovisual recordings, x-rays, books, documents, maps, drawings, photographs, letters, vouchers and papers and any other information that is written, photographed, recorded or stored in any manner”.

Regulated member refers to “an individual who is registered with ACSLPA in any of the categories of membership prescribed in Regulation and in the ACSLPA Bylaws”.

Timely refers to “coming early or at the right time; appropriate or adapted to the times of the occasion”.