I have an independent foot care practice and have been using paper charting but am considering starting to chart in a Word document on my laptop. Is this appropriate?
In every Canadian province or territory, there is legislation to protect the privacy of personal health information (PHI). These laws create obligations as to how the PHI that is normally found in health records can be collected, used and disclosed. These laws also provide guidelines for storing and securing such information.
Usually, this legislation requires the appointment of a “custodian” or “trustee” that has the responsibility to ensure that all the requirements of the privacy legislation are met. For nurses who are employees of a health-care organization, their employer typically takes on that role. However, nurses in independent practice are often considered the legal custodians of the health information and must ensure that the manner in which they collect and store patients’ PHI follows applicable privacy legislation.
In privacy laws, the specific requirements dealing with the storage and security of PHI vary between jurisdictions. However, as a general guideline, the custodian must ensure that the PHI is secure regardless of whether paper or electronic records are used. This may include putting in place a number of safeguards to prevent improper access to PHI. As for electronic records, privacy standards typically require the encryption of electronic files and communications to ensure the security of PHI in the possession of the custodian. Encryption is a process of encoding a message or information in such a way that only authorized parties can access it. Implementing password protection on computers is another minimum safeguard.
In certain jurisdictions, there are additional requirements regarding the electronic storage of PHI. For example, some jurisdictions require that electronic records have the ability to be audited or to create a record of user activity. Because of these requirements, word processing applications like Microsoft Word may not be appropriate. As a nurse in independent practice, you should ensure that your electronic record-keeping follows your regulatory body’s standards and all relevant legislation.
CNPS beneficiaries can contact CNPS at 1-800-267-3390 to speak with a member of CNPS legal counsel. All calls are confidential.
Published May 2017
THIS PUBLICATION IS FOR INFORMATION PURPOSES ONLY. NOTHING IN THIS PUBLICATION SHOULD BE CONSTRUED AS LEGAL ADVICE FROM ANY LAWYER, CONTRIBUTOR OR THE CNPS. READERS SHOULD CONSULT LEGAL COUNSEL FOR SPECIFIC ADVICE.