Record Keeping Quiz

1. In the scenario “Joint Records”, is the record keeping system adequate?

a.  No, because the records are not kept in accordance with College and professional expectations
b.  No, because the people who control the record are not regulated health professionals
c.  Yes, because the person served is a client of the organization, not the dietitian
d.  Yes, because the record is maintained according to the criteria of the dietitian’s employing agency

The best answer is (a). These are health care records and they should be created and maintained according to professional expectations.

Answer (b) assumes that no appropriate record keeping safeguards can be established where non-regulated persons control them. While clearly it is more difficult to ensure that adequate safeguards are in place for unregulated custodians, it is not impossible. Answer (c) fails to recognize that even if the person is primarily the client of the organization, the person is also a client of the dietitian. Answer (d) inadequately reflects the independent professional obligation on the dietitian to ensure that appropriate records are kept. While there is some consideration of the organization’s criteria, the dietitian has a responsibility to ensure that the records are kept appropriately.

2. In the scenario “Joint Records”, what should you do?

a.  Keep your own records separate and apart from the agency’s chart
b.  Make your entries on the agency’s chart but keep a copy for yourself
c.  Discuss with the agency if it will change its record keeping practices to meet the College’s and professional expectations
d.  Explain the situation to the client and obtain his or her consent to follow the agency’s record keeping practices

The best answer is (c). It addresses the issue in a consultative and collegial fashion and could provide the best solution.

Answer (a) may work as a last resort, but requires that you advise the agency of your intent and deprives the others using the chart at the agency from access to your records. Answer (b) only addresses the retention and client access issues. It does not address concerns such as the security and confidentiality of the agency’s copy of the record. Answer (d) is not preferred because it likely involves your discrediting the agency you work with. In addition, obtaining client consent to compromise professional standards is never the best solution.

3. In the scenario “Keeping Private Records”, should you keep separate records and then discard this additional information?

a.  Yes, as no one else needs this additional information
b.  Yes, so long as you get the permission of your facility and do not discard the information for 10 years
c.  Yes, as the official chart contains the minimal information expected by the College
d.  No, private records are too dangerous to keep

The best answer is (b). If the facility agrees to your keeping these separate records and makes appropriate references to them in its record keeping practices, then most of the problems are solved. However, this answer places a burden on you to secure and organize the records appropriately.

Answer (a) misses the point. Even if the others on the team could never want access to the record, other issues need to be dealt with, such as security, confidentiality and access should clients approach the facility for their “complete” record, etc. Answer (c) similarly misses the point. A record, once made, must be treated accordingly. The fact that the official facility chart meets your minimal obligations does not detract from the fact that an additional private record was made. As such, your private record must be linked to the official chart and retained for 10 years. Answer (d) however, implies that the record is filed with the official record and is a possible solution. The reason answer (b) is preferred is because it is more transparent and collegial.

4. Which of the following is not a reasonable security measure for client health records?

a.  Written policies and procedures
b.  Records will never leave the facility
c.  All staff sign a confidentiality agreement
d.  Access to records is on a need-to-know basis

The best answer is (b). It may be necessary to remove a record from a facility for some purposes (e.g. a home visit or to testify at a hearing). Thus, it is better to have appropriate measures for such eventualities than to try to prohibit them entirely. All of the other answers should be part of a security program for client records.

5. Client records should be retained for how long?

a. 10 years from each visit that the client fully completed
b. 10 years from the last assessment date
c. 10 years from the last visit or 10 years after the date the client turns or would have turned 18 years of age
d. 5 years for most diagnostic imaging records

The best answer is (c). This reflects the College’s Professional Practice Standards for Record Keeping. Answer (a) misses that the triggering event is the last client visit.  Answer (b) misses the special provision dealing with clients who are minors. Answer (d) focuses on a minor point. Where other statutes apply, those provisions take precedence. However, it would be rare for the dietitian to have such a record in their chart.