Effective September 2015

The current Documentation and Information Management Standard of Practice (dated September 2015) will remain in effect until such time as the revised draft receives final Council approval.

Draft Standard – June 2020

A draft revised Standard of Practice on Documentation and Information Management is awaiting external stakeholder consultation by Alberta Health. As the consultation process will be delayed due to the impact of COVID-19, the revised version has been made accessible for review by members. The revised Standard complements the recently revised Clinical Documentation and Record Keeping Guideline (June 2020).

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. (2020). 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”.

Standard

A regulated member of ACSLPA maintains clear, confidential, accurate, legible, timely and complete records, in compliance with legislation and regulatory requirements.

Indicators

To demonstrate this standard, the regulated member will:

a)  Maintain and share all documentation, correspondence, and records (e.g., paper based and electronic) in compliance with applicable legislation and regulatory requirements including confidentiality and privacy standards.

b)  Maintain legible, accurate, complete and timely records related to all aspects of client care in either French or English.

c)  Record events, decisions, outcomes, etc. in chronological order.

d)  Include in the record:

  • Name and professional designation of the person documenting the information.
  • Name and professional designation of the person taking professional responsibility for the work (if not the person who created the record).
  • Names and titles of assisting professional service providers and assisting non-professional support personnel.
  • First and last name of the client that the record pertains to, and a tracking number (if one is used). Client identification in the form of either
    a name or a tracking number should be included on each page of the record.
  • Date the record was created.
  • Time that procedures were completed, if clinically relevant.
  • Notation of any change in therapist or support personnel.
  • Notation of chart closure.
  • Evidence of informed consent, whether that be a signed consent form or documentation of a conversation with the client regarding consent, and the resulting outcome.

e)  Include as part of documentation requirements:

  • Relevant case history information, including health, family, and social history.
  • Presenting concern.
  • Dates and brief entries related to any communication to or with the client, including missed or cancelled appointments, telephone or electronic contact.
  • Notation of any adverse or unusual events during the course of assessment or intervention.
  • Assessment findings (including screenings).
  • Plan of care outlining intervention goals and strategies.
  • Response to interventions and progress toward achieving goals documented in the plan of care.
  • Recommendations.
  • Transition/discharge plans, including the reason for discharge.
  • Referrals to other professionals, reports and correspondence from other professionals, equipment, and other services provided.

f)  Include sufficient detail in the record to allow the client to be managed by another speech-language pathologist or audiologist.

g)  For late entries, will include the current date and time, a notation that the entry is late, and the date and time of the events described in the late entry. Appropriate features of the electronic documentation system will be used, as required, to make corrections or late entries.  In some situations, this may mean providing an additional entry that is dated for the day the correction is made, indicating which section of the record is being revised and why.

h)  Ensure that the software used for electronic documentation leaves an audit trail that can reveal when each change was made and by whom.

i)  Minimize the use of abbreviations and acronyms. Any term must be written out in full, with the abbreviation in brackets the first time it is stated in any continuous document entry (i.e., a formal report would constitute one continuous document entry, as would daily chart notes). Subsequent use of the abbreviation in the continuous document is acceptable.

j)  Ensure that all correspondence (e.g., electronic communication, social media) and documentation is professionally written in compliance with applicable legislation and regulatory requirements.

k)  Secure all personal information contained in paper or electronic records, during use, while in storage or during transfer, through the appropriate use of physical, technical and electronic security mechanisms (e.g., passwords, encryption, locked file cabinets, etc.) to protect the privacy of client information.

l)  Access and share information only as needed and in compliance with relevant legislation.

m)  Make a reasonable effort to confirm that all professional electronic correspondence is sent to the intended recipient.

n)  Retain or ensure access to copies of care pathways or protocols in addition to client records in circumstances where client care delivery and documentation is according to a protocol, or where charting by exception is employed.

o)  Maintain complete and accurate financial records for services rendered or products sold when working in private practice or non-publicly funded settings. Financial records must include:

  • Client name or identifier.
  • Name and credentials of the professional, including the practice permit number.
  • Date(s) on which the service was provided.
  • Nature of the service provided (e.g., assessment, treatment, intervention, etc.).
  • Length of time required to provide the service.
  • The actual fee charged and method of payment.
  • Date payment was received and identity of the payer.
  • Any balance owing.

p)  Amend records (e.g., if a client believes that personal information contains an error or omission) according to requirements outlined in the applicable privacy legislation.

q)  Retain records according to the length of time specified by applicable legislation and regulatory requirements:

  • Adult records are retained for 11 years and three months since the date of last service.
  • Records for “persons under disability” are retained for three years and three months after the individual’s death.
  • Records for minors are retained for at least three years and three months after their 18th birthday or for a period of ten years, whichever is longer.
  • Equipment service records should be maintained for 10 years from the date of the last entry.
  • The retention period for financial records required to determine tax obligations and entitlements as per the Canada Revenue Agency is six years.

r)  Retain records in a manner that allows the record to be retrieved and copied upon request, regardless of the media used to create the record.

s)  Provide a copy of the complete clinical and financial record to the client or their authorized representative upon request and appropriate consent.

t)  Take action to prevent abandonment of records (e.g., when closing a practice).

u)  Dispose of records in a manner that maintains security and confidentiality of personal information.

v)  Maintain a log of destroyed files (either paper or electronic), which is kept indefinitely, that includes the following information:

  • Name of each client
  • File number (if available)
  • Last date of treatment
  • Date that the record or file was destroyed.

w)  Be aware of and inform employers, support personnel, and others of their professional obligations regarding documentation and record keeping.

Expected Outcomes

Clients can expect that their speech-language pathology and/or audiology records are clear, confidential, accurate, legible, complete and comply with applicable legislation and regulatory requirements.

Resources and Glossary

Remain the same.