Medical Record Practice at ROMHC: Healthcare Law Assignment Analysis

This report provides a comprehensive analysis of medical record practices at the Royal Ottawa Mental Health Centre (ROMHC). It begins with an introduction to healthcare credentials and their importance, emphasizing accuracy, confidentiality, and completeness. The report then delves into the legislative and regulatory framework governing ROMHC, focusing on the Personal Health Information Protection Act (PHIPA) and the Mental Health Act, and their impact on documentation practices. It outlines the organization's documentation policies, including the use of electronic health records, chronological data entry, and language preferences. The report discusses the audit processes used to ensure compliance with documentation standards and addresses the use of abbreviations, highlighting potential gaps in the policies. Furthermore, the report emphasizes the role of Health Information Management (HIM) as an advocate for maintaining patient privacy, integrity, and adherence to ethical standards. The conclusion summarizes the key findings, reinforcing the importance of legislative compliance and HIM guidance in the context of mental healthcare.

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

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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.

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This organisation follows some rules and regulations for recording patient information.
The ROMHC carries out medical record audits consistently to confirm that information is correct
and is performed according to the documentation standards. The authorised committee comments
on the audit.
ROHCG provides privacy, protection to the patient's health data as it is necessary by the
law. Moreover, these data are irrespective of oral, written, or electronic. This organisation aims
to provide the proper care of the patient and the effective use of ROMHC resources. All the
personnel are responsible for implementing these rules and regulations, and all the information is
regardless of the procedures. The organisation ROMHC has permission with the provision of the
PHIPA and Mental Health Act. An example is given to clarify this. If any employee of this
organisation is admitted to ROMHC, they will also be treated as a patient, and a clinical record
must be followed like other patients according to the stated policy. Nevertheless, there will be an
exception for this type of patients, and they will be admitted under Occupational Health. This
policy does not come under the documentation policy, but privacy should also be maintained
here, and in case of any violence of rule, the employee should be dismissed from this
organisation.
The use of abbreviations
The abbreviation practice that is scripted in the organisation ROMHC is addressed in one
way, which means it is described as a negative aspect only. The detrimental effect of
abbreviations, symbols and the dosage of drugs are mentioned here. The abbreviation practice is
only categorised by their encoded meaning, misinterpretation and possible correction. No
specific rules are referred for writing the abbreviations and other things. There are no current

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legislations about the customs of the acronym (Shahabuddin, Ahmat & Teh, 2015). The
perspective of approaching the method of abbreviation is not in accordance with the law directly.
There is no reference for rules in the ROMHC policies and customs. Standard guidelines for
using these symbols and abbreviations should be implemented for the proper medical record
credentials of a patient. For the execution of this purpose, a suitable layout would be needed. For
simplicity of indication, the abbreviations should be divided into the following categorisations.
They are-
 Medical or drug dosage abbreviations
 Symbols
 General abbreviation
 Role-specific or service provided the abbreviation
 Chosen therapy associated abbreviation
It should be noted that when there is more than one meaning of acronyms, then the
abbreviations should not be used in this context. Since it would create confusion and
misconception to the health care providers along with other staff associated with the health
system, the word should be written in full. A new law should be formulated which particularly
would be assigned for this organisation, ROMHC. Under this regulation, an appropriate
guideline should be provided so that all the staff linked with this organisation can abide by this
rule for further certification related to principals, symbols, therapy-related abbreviations, and the
dosage of drug abbreviations and so on. An advisory committee should be formed that will revise
the rules on time, supervise the whole process, and maintain the method of abbreviations in
terms of the law. There should be an approved list in which only permitted symbols and

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abbreviations should be pointed out, and this list would be dispersed among the health care
service providers with a current record in this organisation.
Gaps in the policies:
The abbreviation guidelines referred in this organisation are described in a negative
aspect; only restrictions and its supporting corrections are given. However, useful guidelines
should be cited as all procedures should have both positive and negative aspects. There should be
a standard policy regarding the abbreviation procedure. An excellent clinical record consists of
patient consent certification. As per this organisation, it is not applicable always since the patient
is not in a healthy condition. Nonetheless, the consent should be taken from the guardian on
behalf of the patient.
Justification of HIM as an advocate:
Health Information Management (HIM) incorporates a wide range of opportunities that
diverse roles according to the organisations. An HIM has the responsibility to manage medical
records irrespective of format (paper or electronic), inventor (nurse, specialist) and purpose
(research, care or funding). The principal responsibility of a HIM is to maintain privacy,
integrity, rules and regulation of clinical documentation of the patient. Possessing these
characteristics, an HIM has detailed knowledge about the plan and developing a new policy.
They can apply it to gather, analyse, use and transform to gain legal, ethical and professional
practice of documentation for the medical care system. Being an advocate, HIM has also
complete acquaintance with laws regarding this issue. These characteristics will add a golden
feather to the HIM that will credit an extra benefit in this matter. The record of the patient
information and also the patient's health data are very confidential. This recording procedure falls

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under the law, PHIPA. As a result, when any violence or legal cases will arise, the employees,
who are assigned to this job, will be interrogated first. They will have to show the document to
the authorities and also the legibility will be checked. It is more important for this organisation,
ROMHC, as it is concerned with mental illness patients. They are not in a healthy state to give
proper evidence against this. It is seen that many times the patient consent information cannot be
taken as they are not well. According to the Canadian Health Information Management
Association (CHIMA) code of ethics, all the staff should not disclose the patient information
apart from official persons, avoid violation of any organisational law and should behave within
the organisation. If any new proposal is employed, the employees should follow this as the
ethical issue is concerned. Since this organisation is a health centre and is worried about only the
mental patient, the moral question is raised when personal history is taken for the documentation
process.
Conclusion
Therefore, from the above discussion, it can be concluded that the documentation process
of ROMHC that is mental health care are discussed here. Some legislation should be followed
for recording the data of a patient. Electronic Health Record maintains the documentation, and
there are some guidelines to support it. The organisation performs audits regularly to confirm the
documentation standards. The second point is about the use of abbreviations and legibility of this
organisation and the measures taken to improve the practice are- proper symbols and
abbreviations. Here, five segments of acronyms are suggested for the association. The last part
offers that the health care service providers should keep in mind this knowledge. In association
with health information management that supports health care credentials, certification and also

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the Canadian Health Information Management Association (CHIMA) code of ethics, the staff
related to other health professionals should follow the guidance of HIM as an advocate. Since
this organisation is concerned with mental health care, the ethical aspect, examination of the
patient for gathering information, and the supportive laws are present to analyse this.

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Reference
Kuhn, T., Basch, P., Barr, M., & Yackel, T. (2015). Clinical documentation in the 21st century:
executive summary of a policy position paper from the American College of
Physicians. Annals of internal medicine, 162(4), 301-303.
Shahabuddin, A., Ahmat, N. H., & Teh, P. C. (2015). A study on the use of abbreviations among
doctors and nurses in the medical department of a tertiary hospital in Malaysia. Med J
Malaysia, 70(6), 335.
Mathioudakis, A., Rousalova, I., Gagnat, A. A., Saad, N., & Hardavella, G. (2016). How to keep
good clinical records. Breathe, 12(4), 369-373.
Byrick, k. (2020). a practical guide to mental health and law in ontario [Ebook]. Retrieved from
https://blg.com/en/News-And-Publications/Documents/Publication_4649.pdf
Saranto, K. (2014, July). Clinical documentation improvement for outpatients by implementing
electronic medical records. In Nursing Informatics 2014: East Meets West ESMART+-
Proceedings of the 12th International Congress on Nursing Informatics, Taipei, Taiwan,
June 21-25, 2014 (Vol. 201, p. 102). IOS Press.

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