Healthcare Credentials

Running head: MEDICAL RECORD PRACTICE IN ROMHC
MEDICAL RECORD PRACTICE IN ROMHC
Name of the Student
Name of the University
Author Note

MEDICAL RECORD PRACTICE IN ROMHC1
Introduction
The healthcare credentials are a composed layout of maintaining a patient's clinical
history, the analysis, and evaluation, the prescribed tests, diagnosis, provided care system,
treatment procedure, progress report. This report is also maintained to connect with an outside
medical practitioner, to serve in any legal or statutory events, to show evidence against any
complaint, and even for education or research purpose. This documentation depends on five
major issues, such as accuracy, confidentiality, timeliness, significance, and completeness. The
record should contain clear, structured and detailed information about the patient. In the time of
writing or recording, it must sustain the available rules and regulations of healthcare-related
documentation. This paper briefly describes the medical documentation practice of an
organisation named as Royal Ottawa Mental Health Center (ROMHC). This paper also focuses
on the legislative engaged in the clinical record of the patient and the guidelines followed in
undertaken documentation. The next section describes the documentation policies and audits
accompanying the current rules and principles of the organisation. After that, the use of
abbreviations, the legitimacy and the probable requirements are conferred to change the strategy.
Finally, the paper will cover the justification of suggesting any recommendation as an advocate
that is implemented in this organisation.
Discussion
Specification of the judicial and laws maintained in the documentation:

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Regulations of almost every healthcare management strictly conserve the subject matter and
supervise the medical record of the patient. Since the documentation is needed for audit purposes
or any court case, and it provides the complete data and confidentiality of the patient, the
stringent rules are implemented in this context. The central regulatory bodies that concern about
the mental illness people are Consent and Capacity Board (CCB) and the Ontario Review Board.
The CCB conducts authorities to hear the problem under many statuettes; the Mental Health Act
(MHA), the Substitute Decision Act (SDA), the Personal Health Information Protection Act
(PHIPA). The legislation that governs the organisation, Royal Ottawa Mental Health Center, is
the PHIPA. This act was implemented in 2004 and described the uses, assemblage and exposure
of private information of the patient. The health care assistant should clearly understand the rule
of how the increasing demands of mental health care misinterpret the role of caregivers of taking
personal information under PHIPA. In the law, it is also discussed about the situation where the
Mental Health Act should be the priority over the PHIPA. Health employees should know that
patient care is more important than any other thing. The staff must gather, use, and reveal the
patient's data without his/her consent when it has a connection with the patient's examination,
confinement and evaluation under MHA (Byrick, 2020). For maintaining the professional
association, some principals are retained. For example, ROMHC is a mental health care centre.
The documentation practice should be followed according to the institution. In this organisation,
documentation is done by electronic health records (EHR). From the given Royal Ottawa Health
Care Group's (ROHCG) corporate policy and procedure, the followed clinical documentation
standards are mentioned below:
 The documentation should describe the full information of care, including analysing,
treatment procedure, and recovery progress, the idea of the disease, proposed research,

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and doctor consultation. The medical record should be significant, patient-centred,
complete, accurate and meaningful interventions. The information that is not associated
with the patient's data is not documented.
 The data needs to be entered, should be in chronological order that detailed the latest
patient's entry, date of admission, and electronically signed by the official person.
 The approved language is English, only permitted abbreviations and Electronic Health
Record methods are used.
 Always English is preferred for the medical record, but in exceptional cases, French is
also used, for example, quotes from the patient.
 The record should be completed at the time of providing care. There will be no spaces or
lines for extra data. Raw data should be avoided from marching with the patient folder.
 The documentation must be clear, accurate, and time of entry and date should be
mentioned.
 Health Information Management (HIM) professionals should ensure the relevant patient
information and completeness of the data.
Policies and Audits
All the staffs who are working there they must follow the strategies and rules of
documentation of the organisation. They maintain all the data, such as the personal information
as well as private health data provided by the patient, whether it is written, oral, or electronically
collected. The employees abide by the protocols of the Patient Health Information Protection Act
(According to the Royal Ottawa Mental Health Care, Corporate Policy, and Standards). In this
way, this organisation confirms that the medical records are followed under this act.