Electronic Record Keeping
28.10.2016
Barry Allen, a licensed optician, recently switched from paper patient records to storing all his patient records electronically. He is unsure about what he needs to consider when managing patient records all electronically and how often he should back up his patient records. Barry is aware that the dispensary's computer is password protected, but the computer is getting old and Barry does not want to lose all his patient records due to a system crash. He also works with a couple other opticians. What should Barry consider? 

Factors to consider: 
1) Ensuring protection of patient privacy
2) Ensuring access to patient records
3) Ensuring accurate patient records and backup contains most up-to-date information 
4) How long to store electronic patient records 

The COBC Standards of Practice represent the profession's norm for good practice. There is also multiple legislation in place that opticians need to consider for record keeping such as the Personal Information Protection Act, Consumer Protection Act, and the Freedom of Information and Protection of Privacy Act. It is the responsibility of each optician to exercise professional judgement when determining the needs of patients. 

Barry and the opticians that practice at the same location need to ensure there is a framework in place that is going to work. Patient records contain a lot of personal information such as date of birth and patient history. If patient records are going to be stored electronically, the hard drive and server needs to be secured so that patient records cannot be accessible by anyone without permission. This includes password protecting record keeping software and computers and making sure only authorized people can view the screen when looking at a patient file. In addition, if anyone without permission got access to patient records, opticians are expected to contain the breach and notify any patients affected to avoid/mitigate harm. 

The patient record management software used should allow opticians to document information like prescriptions and assessment records, assessment and recommendations, and who did what for the case history. The goal is accurate patient records reflecting exactly what happened during each patient interaction. 
Opticians are expected to maintain patient records so that it could be retrieved at any time. Since Barry maintains electronic records, it is expected to be electronically backed up regularly (eg: daily) and in a remote location in case something happens so that data is not lost. Barry should ensure backup should occur regularly enough to ensure that if anything happens, files are kept accurate.  Records should also be kept for at least 3 years but suggested up to 10 years as per other health professionals. 

There are many ways to backup records electronically. Each individual should research what will be the most effective and secure way for their practice keeping in mind patient confidentiality. 

Reference:
 
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