Frequently Asked Questions > Team Member Documentation


QUESTION — TEAM MEMBER DOCUMENTATION

Can team members document for one another?

RESPONSE

Documentation is an essential element of care.  Every regulated health professional is required to document the care they have provided in accordance with the standards of practice of their profession.  Each professional should be aware of the requirements of their own regulator and ensure that they meet these requirements.

Only in specific circumstances should a health care provider document for another member of the team, and in those situations, it must be clear who had the first-hand knowledge of the event, who performed the activity, and who recorded the activity. Examples of documentation on behalf of a team include a flow sheet or code blue record.

Ultimately, when a team member documents on behalf of the team, each team member remains individually accountable for the care they provide and to ensure the record of that care is accurate and complete.

LINKS

Long-Term Care Homes Act, 2007

Retirement Homes Act, 2010

COLLEGE LINKS
Acupuncturists
Audiologists

Proposed Records Regulation, 2011

Chiropodists
Chiropractors

Standard of Practice S-002: Record Keeping and Standard of Practice S-022: Ownership, Storage, Security and Destruction of Records of Personal Health Information

Dental Hygienists
Dental Technologists
Dentists

Guidelines – Dental Recordkeeping (see Professional Practice (Advisories, Standadrs, Guidelines): Guidelines)

Guidelines – Electronic Records Management (see Professional Practice (Advisories, Standadrs, Guidelines): Guidelines)

 

Denturists
Dietitians

CDO’s Record Keeping 

Homeopaths
Kinesiologists
Massage Therapists
Medical Laboratory Technologists

CMLTO Delegation Guidelines for MLTs

 

Medical Radiation Technologists

CMRTO Standards of Practice 

Midwives
Naturopaths
Nurses

Documentation

Documentation Learning Module

Occupational Therapists

COTO Standards: Record Keeping

Opticians

Standard #6 – Records

Optometrists

OPR 5.1  The Patient Health Record

 

Pharmacists

Documentation Guidelines for Pharmacists

Pharmacy Technicians
Physicians and Surgeons

CPSO Policy Statement #5-05: Medical Records

Physiotherapists

Practice Tool - Record Keeping Check List

Standard for Professional Practice - Record Keeping

Guide to the Standard for Professional Practice - Record Keeping

Podiatrists
Psychologists
Psychotherapists
Respiratory Therapists

CRTO Professional Practice Guideline- Documentation Documentation

CRTO Professional Practice Guideline: Orders for Medical Care (verbal orders) 

Speech-Language Pathologists

Proposed Records Regulation, 2011

Traditional Chinese Medicine and Acupuncturists