Self-Assessment: Record Keeping

Naturopathic Doctors are required to retain and maintain accurate, legible and comprehensive records of all patients, be it in written or electronic forms. This must be done in accordance with the Personal Health Information Protection Act, 2004 (PHIPA) and the College’s Standard of Practice for Record Keeping.

The Personal Health Information Protection Act establishes the rules for the collection, use, and disclosure of personal health information about individuals that protect the confidentiality of that information and the privacy of individuals with respect to that information, while facilitating the effective provision of healthcare.

This self-assessment tool has been developed to help Registrants meet their professional and legal obligations and to advise Registrants with respect to the expectations for record keeping in their practice.  It uses questions to help you assess your record-keeping practices and should be read in conjunction with the resources listed below.

Three Step Process – Read, Identify, Review and Modify

1. Read our resources
All record keeping resources are published on the College of Naturopaths of Ontario’s website.  These resources have been developed to help naturopaths identity, assess, and ensure appropriate patient records.

They include:

2. Identify
Identify all aspects of the patient record.  These include the patient chart, appointment records and financial records.

3. Review and Modify
You should regularly review your record keeping practices to ensure that they comply with the College’s regulations and standards of practice.  Where the standards are not met you should review and consider what steps will be taken to ensure compliance and improvement in your record keeping practices.

Remember, it is the ND’s responsibility to maintain accurate, legible, and comprehensive personal health information records of all patients, and in a manner that ensures continued access by the patients or the College.