Scenario: Keeping Private Records

You work at a facility with other health professions. The facility has an approved form that it expects all members of the health care team to follow. You place the traditional information (medical history, major findings from assessment, treatment plan) on the approved form.

However, there is not an appropriate space to put your detailed meal plan calculations and energy intake notes; these entries are rough and messy, and you would be embarrassed to put them in the main chart. They would be of no use to anyone but you. Can you keep those notations in a separate file that you keep as long as you are seeing the client and then discard?

The temptation by practitioners to keep their own records separate from a central record keeping system is illustrated in this scenario. This practice is not recommended. The difficulty is that keeping private records prevents the facility or organization from meeting its own record keeping obligations (e.g. maintaining security, providing access to clients, and destroying the record in accordance with an established retention policy).

Private records consist of entries that are not included in the official chart of the facility or employer for whom a dietitian works. Unlike rough notes, which can be destroyed after they have been completely transcribed onto the official chart, these records are typically maintained by a dietitian for some time for private use.

There are a number of reasons why a dietitian might wish to keep a private record:

• The official chart requires a form that does not lend itself to recording all of the information the dietitian wishes to record;
• The employer or facility discourages the extensive recording of information that the dietitian wishes to do or that is required by the College;
• The official record is inconvenient to access, because of the procedures, the length of time it takes to retrieve the record, or because others are often using it;
• The dietitian believes that the information handling policies of the facility or employers do not permit compliance with College regulations or other legal requirements (e.g. providing adequate access to clients);
• A dietitian’s private record tends to be messy and not in a form that is useful or appropriate for others on the health care team to see;
• On rare occasions, the dietitian may be concerned about the lack of privacy afforded to the official record (e.g., where very private information is revealed that a client does not want the entire team to know, or where the employer or facility is privately owned and does not respect confidentiality); or
• The dietitian is concerned that a copy of or access to the official record will not be given when leaving the facility or the job.

• It is difficult for the information policies of the facility or employer to apply to a dietitian’s private record (e.g., it might not be kept with the same degree of security as the official record);
• Valuable information may be inaccessible to the rest of the health care team; and
• The legal obligations of the facility or employer cannot be fulfilled. If a client wishes to exercise his or her right to see the entire file, the facility or employer cannot provide this access where it has no knowledge of the dietitian’s private record. Or if the entire chart is required to be produced in a legal proceeding, the private record will not be included, placing the facility or employer in contravention of the law.

• Do not keep private records. Record everything that needs to be recorded in the official chart.
• Advise the facility or employer that you are keeping private records and negotiate appropriate policies and procedures respecting them, such as access by others, security and ability to remove private records when leaving, etc.
• Discuss with the facility or employer the reasons for keeping private records in the first place, so that any underlying issues are appropriately addressed.