Collaborative Record Keeping for Dietitians in Ontario
As a registered dietitian, you often work
in teams with other practitioners to deliver client care.
Your client health care records may be the
primary or only mode of communication you
have with the rest of your clients’ health
Good record keeping is key to good team work.
So, what does good record keeping look like
in a collaborative environment?
Your documentation must be legible and understandable.
This means that your records are readable
and the person who provided care is indicated.
Avoid profession-specific terms and abbreviations
that are not generally understood.
Also, avoid statements that are false, misleading,
All entries should be in either English or
Your documentation must be timely.
Timely may mean immediately after a client
interaction, within the same day, or something
else, depending on your practice setting.
Use your professional judgement, and follow
Ensuring that all the relevant nutrition care
information is formally captured in the record
is an obligation of all dietitians.
Your client and your team depend on it.
You play a vital role in interprofessional
record keeping and communication to facilitate
quality client-centered care.
For more information search “record keeping”