Your Client Health Record: A Key to Quality Nutrition Care From Your Dietitian
Did you know that when you receive nutrition care from a Registered Dietitian, they keep a client health record? Your client health record contains your personal health information with details of your medical history, nutrition assessment and care plan. This information helps dietitians keep track of what happened at your appointment and what to do next to help you.
A Registered Dietitian often works in teams with other health practitioners. Client healthcare records may be the primary or the only method of communication a dietitian has with the rest of your health care team. Your record is shared with other health providers to make sure all your health professionals know what has happened in previous appointments. If you have a nutrition-related condition such as diabetes, this important information can impact the treatment you receive from the other health providers in your healthcare team.
Standards for Health Records
The College of Dietitians of Ontario has standards of practice for keeping healthcare records. The College is the regulatory body that oversees dietitians. The standards help dietitians meet their record keeping obligations. The College works to ensure good record keeping through education and compliance programs for dietitians such as practice advice, quality assurance and complaints.
An important standard is that a dietitian’s client health records must be legible and understandable. If you ask to see your health record, you should be able to read it and understand it, and so should the other members of your healthcare team. It should also be up-to-date. All the information related to your care should be in the record.
Timely documentation ensures the right people have the right information at the right time. Your record will include the name of the dietitian and the others involved in your health care, details of your nutrition treatment, a record of your appointments, any recommendations that were made and the details of any billing.
Dietitian’s must keep your health record for at least 10 years after your last visit. In most cases, you have the right to control who has access to your health care information. You also have the right to access your own health care record, correct errors and obtain copies when you want them.
If a dietitian leaves their private practice due to retirement, a move or any other reason, they are required to tell your where the records will be transferred to so that you can always have access to them.
Ensuring that all the relevant nutrition care information is in your record, and that you have access to your health record when you need it, is an important obligation for all dietitians in Ontario. You and your healthcare team depend on it. Keeping a good client record is key to your care.