Definitions
....This type of information may or may not become part of the client’s health record. They may be destroyed if not needed, but if they exist at the time that access is sought to the record, they are considered a legal part of the client’s record.
Rough Notes
An individual identified in a personal directive or provincial legislation who may make decisions on behalf of the client when the client is deemed incapable of making a decision in the specific domain
Substitute Decision Maker
This type of information is recorded for standardized or non-standardized assessments which have not been converted into scales scores or modified by statistical means. Raw data includes any sources that are used to form your clinical opinion. Raw data can be a variety of formats including, video tape, audio recordings, print, or electronic. It can include such things as emails, completed assessments and forms, invoices, faxes, etc.
Raw Data
An outline of anticipated care, placed in an appropriate timeframe, to help a client with a specific condition or set of symptoms move progressively through a clinical experience to anticipated positive outcomes. It can also be referred to as a clinical pathway, protocol or care map.
Care Pathway
A method of client care documentation that uses a pre-determined plan whereby only unusual occurrences, changes to that plan, or significant findings are recorded.
Charting by Exception