Quality Assurance

PATIENT MANAGEMENT

ADVISE AND DISCLOSURE

PURPOSE OF THE STANDARD

The purposes of the standard is to ensure patients receive an appropriate evaluation from their history, examination and assessment/diagnostic procedures as a prerequisite for the delivery of removable dental prosthesis.

DESCRIPTION OF THE STANDARD

Where an assessment/diagnosis is made; the following must be communicated:

1. Treatment plan; and
2. Prognosis, and when treatment is completed, post insertion education; and
3. Fees

REFERRAL PROCEDURE

When a treatment plan cannot be completed without a referral, the procedure must be communicated to the patient and recorded in the patient file. All documentation received from other attending or consulting professionals shall be maintained with the patient file.

SCOPE OF PRACTICE

Treatment provided shall at all times fall within the legislated parameters of professional and individual competency boundaries of the member/practitioner based upon personal skill, knowledge and training.

SUMMARY AND CONCLUSION

Consequences of non-compliance to this standard may lead to patient confusion, member inconvenience and ultimately legal implications.

Back to top

PATIENT RECORDS

PURPOSE OF THE STANDARD

The following standard is intended to ensure that a member maintains a minimum level of documentation in accordance with the existing regulations. Refer to attached APPENDIX A for 2.2.2. Summary and Conclusion Consequences of non-compliance to this standard may lead to patient confusion, member inconvenience and ultimately legal implications.

APPENDIX A for 2.2.2 RECORD KEEPING REGULATIONS (Ontario Regulation pending proclamation).

RECORD RELATING TO A MEMBER'S PRACTICE

4.    (1) A member shall, in relation to his or her practice, take all reasonable steps necessary to ensure that records are kept in accordance with this regulation.
       (2) Reasonable steps under subsection (1) shall include the verification by the member, at reasonable intervals, that the records are kept in accordance with this regulation.

5.    A daily appointment record shall be kept that sets out the name of each patient who the member examines or treats or to whom the member renders any service.

6.    (1) A financial record shall be kept for each patient.
       (2) The financial record must contain a notation of the charges made and payments received in respect of services and supplies provided to the patient.

7.     (1) A patient health record shall be kept for each patient.
        (2) The patient health record must include the following:

1. The patient's name and address.
2. The date of each of the patient's visits to the member.
3. The name and address of the primary care physician and any referring health professional.
4. A dental and relevant medical history of the patient.
5. Reasonable information about every examination performed by the member and reasonable information about every clinical finding and assessment made by the member.
6. Reasonable information about every order made by the member for examinations, tests, consultations, or treatments to be performed by any other person.
7. Every written report received by the member with respect to examinations, tests, consultations or treatments performed by other health professionals.
8. Reasonable information about every referral of the patient by the member to another health professional.
9. Reasonable information about every fee or other amount charged by the member.
10. Reasonable information about a procedure that was commenced but not completed, including reasons for non-completion.
11. A copy of every written consent.

        (3) Despite subsection 7-(2), if the only service a member provides is a repair of a denture that the member did not fabricate, the records for the repair need only contain,

(a) the patient's name, address and telephone number
(b) the date and nature of the repair

        (4) Every part of a patient health record must have a reference identifying the patient or the patient health record.

        (5) Every patient health record shall be retained for at least five years following the patient's last visit.

8.     (1) This section applies to clinical records kept by a member in his or her office in respect to a patient.

        (2) A member shall permit a patient or his or her authorized representative to examine and copy, upon payment of reasonable fee, the clinical records kept in respect of the patient unless:

(a) the member has reasonable grounds to believe that the examination or copy creates a significant likelihood of a substantial adverse effect on the physical, mental or emotional health of the patient; or
(b) the member has reasonable grounds to believe that the examination or copy creates a significant likelihood of substantial harm to a person.

        (3) A person who examines or copies a record under subsection (2) may request, in writing, that the member correct the record where the person believes there is an error or omission.

        (4) A member who receives a request under subsection (3) shall:

(a) make the requested correction; or
(b) attach the request to the clinical record.

        (5) A member who receives a request under subsection (3) shall, if asked, provide to the person making the request the name and address of any person to whom the record was sent in the twelve months before the request was received.

9.     (1) Where in this regulation a notation, report, record, order, entry, signature or transcription is required to be entered, prepared, made, written, kept or copied, the entering, preparing, making, keeping or copying may be done by such electronic or optical means or combination thereof.

        (2) The member shall ensure that the electronic or optical means referred to in subsection (1) is so designed and operated that the notation, report, order, entry, signature or transcription is secure from loss, tampering, interference or unauthorized use or access.

10.   (1) It is an act of professional misconduct for the purposes of clause 51(1)(c) of the Health Procedural Code for a member to fail to take reasonable steps, before resigning as a member, to ensure that for each patient health record for which the member has primary responsibility:

(a) the record is transferred to another member; or
(b) the patient is notified that the member intends to resign and that the patient can obtain copies from the patient health record.