Confidentiality (LTC)

Origination: 07/2010

Last Approved: 01/2022

Last Revised: 01/2022

Next Review: 01/2024

Owner: Maria Cherbel

Manual: LTC- Resident Care

Category: Records

GOAL

UniversalCare is committed to resident centered care through excellence and innovation. Each resident is an individual and must be treated as such through:

  • Accountable interdisciplinary approach to care where the resident is seen as an individual
  • Holistic approach to care based on each resident’s believes, culture, background, race, religion, spiritual and psychosocial needs
  • The plan of care shall be based on rehabilitation
  • Meet the corporate standards and all the applicable legislations and best practices
  • Create an environment that will foster everyone’s safety

PURPOSE

All staff receives information regarding the confidentiality of resident records.

The Home has a written policy, based on the Fixing Long-Term Care Act, 2021, and MOHLTCH regulations, describing limitations on access to resident records.

There is a locked area for secure storage of records.

POLICY

  • Security and confidentiality of the medical record shall be maintained in the home at all times.
  • The Administrator, the Director of Care or delegate, may release residents’ names, reasons for admission, treatments and conditions.
  • The Administrator or the Director of Care must obtain written approval of the resident or his legal attorney or substitute decision maker before disclosing any clinical information.
  • Discussions regarding residents or their conditions must be avoided outside the Home and public places.
  • Care must be taken not to discuss Long Term Care Home business in front of the residents.
  • No false or malicious statements should be made.
  • Staff must not repeat rumors.
  • Clinical Records are confidential and are only available to authorized staff.
  • Residents’ records must not be removed from the Home with the exception of a court order.
  • The following persons may inspect and receive information from a resident’s medical or drug record and may reproduce and retain copies there from:
  • The resident’s attending physician or dentist.
  • A member of the nursing staff or the pharmacist in the LTCH.
  • The administrator of another LTCH to which the resident has been transferred. All disciplines of the Multidisciplinary Care Team may document relevant information on the resident’s medical record. Requests for release of confidential information shall be directed to the Administrator or designate.
  • All disciplines of the Multidisciplinary Care Team may document relevant information on the resident’s medical record.
  • Requests for release of confidential information shall be directed to the Administrator or designate.

PROCEDURE

  • Charts must be kept in the chart racks within the nurse’s station when not in use.
  • Charts belonging to discharged or deceased residents are to be kept at the Nurse’s station until the physician writes the final note, or for no more than seven days.
  • Upon receipt of the said medical record, the Director of Care shall ensure completion by the physician within 14 days and forward same to Record Storage.

KEY NOTE

  • Failure to insure confidentiality of records may result in complaints and financial liability for facility.

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