Scenario: Joint Records

You work as a dietitian in a public health unit and participate in a prenatal nutrition program for high-risk expectant mothers. The program is operated by an independent community agency and the clients are those of the agency, not the public health unit. Your notations are kept only in a record on the premises of the agency. You know that the agency does not follow the College’s expectations for chart security and retention. Are you at risk for this record keeping approach?

Dietitians often work in settings where they are expected to use a joint record, because this makes practical and clinical sense for a team practice. However, this places some obligation on the dietitian to ensure that the record keeping practices of the facility, employer or team are consistent with the expectations of the College and the dietetic profession. Professionals in public facilities such as hospitals, government departments or settings where only health practitioners work are more likely to share the same values and approaches. Even in these situations, dietitians should check record keeping practices to ensure their quality.

Where the employer, facility or program is privately operated, the dietitian may need to exercise a higher degree of scrutiny of the record keeping practices. In this scenario, the records are partially those of the dietitian, so he or she has to ensure that the facility meets minimal professional expectations. Usually this can be achieved by communication between the parties. Refer to the Professional Practice Standards for Record Keeping for the minimal expectations that dietitians must meet in their dietetic practice when keeping records.

Where the facility, employer or program does not meet the record keeping expectations of the dietetic profession, the dietitian must advocate for a change to the practices or, failing to reach compliance with the College’s regulation, may need to keep separate records. This should not be done secretly (see Keeping Private Records Scenario).

It is important to resolve record keeping issues when starting a position. If a dietitian is in an employment situation where they have record keeping issues, it’s important to resolve them immediately. Once a relationship ends or a dispute arises, it may be more difficult to resolve them. In some private practices, the employment or partnership agreement should indicate who is the health information custodian and if the dietitian is an agent, how they may obtain necessary access to records. If the health information custodian is not a dietitian, there should be explicit agreement to comply with the College’s expectations and the Personal Health Information Protection Act, 2004.