Whether you currently use electronic records or are thinking of converting from paper to digital, we offer the following tips in response to questions we have received from Members.

1. Regardless of whether your patient records are paper or electronic, the same content requirement outlined in the Standard of Practice for Record Keeping apply. For example, the patient chart should always include their chief complaint, relevant health and family history, subjective and objective findings, assessments, diagnosis, and treatment plans (see section 3 of the record keeping standard).

2. Once you have converted your patient records from paper to electronic and have ensured that the content has been converted in its entirety, the paper copy may be disposed of in a secure manner. This means that once the paper version is destroyed, such as by cross-shredding, the record cannot be reconstructed.

3. When you leave a practice and are taking the electronic records with you, as with original paper files, the clinic you are leaving does not retain a copy of the patient's record. For electronic records this would include ensuring there are no electronic copies remaining at the clinic. However, where it is agreed that the clinic will remain the custodian of the records, they remain responsible for maintaining the electronic records and must provide you with access in the event of a complaint or legal investigation.

4. The College does not approve the software or apps that Members may use. NDs are responsible for ensuring the platform they use is in compliance with the record keeping standard.

5. One specific aspect of the software or app that Members may not stop to consider is that the storage of the information  must comply with Ontario's privacy laws. When the information is being stored in a cloud-based format, naturopaths must ensure that it is compliant with the Personal Health Information Protection Act, 2004. Apps that are compliant with the Health Insurance Portability and Accountability Act (HIPAA), which is a US law, are not necessarily compliant with Ontario laws.

6. You may use an electronic consent form which the patient can "sign" by checking a box that represents their signature. As always, consent forms should not be signed before a conversation with the patient. The process of obtaining informed consent is ongoing, and involves a conversation which allows the patient to ask questions and is documented.

7. Some software and apps do not allow for an audit trail. You must be able to show who accessed the patient file; when they did so; and what information they added, changed or removed.

For additional queries about record keeping and other practice-related issues, contact our Regulatory Education Specialist Dr. Mary-Ellen McKenna ND (Inactive) at 416-583-6020 or maryellen.mckenna@collegeofnaturopaths.on.ca