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Documentation

Canadian Nurses Protective Society > Documentation

Ask a lawyer: Documentation of late entries

Question 1: Do late entries hold the same weight in court as multiple small timely entries? Answer: A late entry is one which is not made as soon as possible after an event has occurred. It is required when it is not possible to document at the time of or immediately following an event, or…

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Ask a lawyer: Electronic medical records and independent practice

Question: 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? Answer: In every Canadian province or territory, there is legislation to protect the privacy of personal health information (PHI). These laws create obligations as to…

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InfoLAW: Evidence

Facts are central to any legal decision. Only once the facts of the matter have been determined by the court can the relevant law be applied and a decision rendered. The basic rule of evidence is that information can be admitted as evidence where it is relevant to a material issue in the case. Other…

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InfoLAW: Privacy and Electronic Medical Records

Electronic medical records (EMR) are now common to most nursing practices. To protect the privacy of patients’ personal health information, nurses should be aware of the unique privacy issues related to the use of EMR. Privacy Risks Access An increasing number of privacy breach cases involve unauthorized and inappropriate access by employees into their employer’s…

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InfoLAW: Quality Documentation: Your Best Defence

The Canadian Nurses Protective Society (CNPS) frequently receives requests for information regarding documentation issues or concerns. Nurses working in all areas of patient care encounter issues related to documentation, whether in paper or electronic form. Quality documentation can be a nurse’s best defence in the face of a complaint, claim or legal proceeding. Addressed below…

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