Disclosure Documentation
In general, clinicians should focus on keeping Connect Care information within Connect Care. All information sharing must comply with Connect Care information sharing norms and provisions of the Clinical Information Sharing Approach (CISA). The CISA outlines how health data is collected, accessed, used, disclosed and exchanged in the Connect Care clinical information system (CIS).
Chart Access for Information Release
Responding to Information Requests Directly Related to Patient Care
Clinicians may receive requests for health information in Connect Care from external parties also supporting a patient's care. Examples include information required for employment, education, insurance, travel, compensation or other health-status-contingent needs. The Alberta Health Information Act (HIA) supports release of such information by an authorized facility, unit, clinic, department or clinician; with a requirement that all disclosures of patient identifiable health information be recorded.
Connect Care supports appropriately documented release of information by clinicians through two main tools. The associated workflows are illustrated in tip sheets:
Quick Release
when the patient is present and requests information release, use Quick Release to capture who the information is being released to, the purpose of the release, and what information is being released.Quick Disclosure
when printing or otherwise extracting information to provide directly to the patient, authorized representative or proxy.
Clinicians may choose to not release information themselves. They can seek help from, or refer external requestors to, the AHS Health Information Management (HIM) Access and Disclosure helpline (1-855-312-2265 or disclosure@ahs.ca). All "complex" or "high risk" requests (see Guide below) should be referred to HIM. HIM can also handle direct requests from patients for Connect Care content.
Telephone: 1-855-312-2265
Facsimile: 1-855-935-0646
Email: disclosure@ahs.ca
Responding to Information Requests Indirectly Related to Patient Care
While patient charts should only be accessed by clinicians in the patient's circle of care for "direct" patient care, the HIA and CISA support information access for functions "indirect" to patient care. These include:
Supporting patient employment, education, insurance, travel, compensation or other health-contingent needs
Promoting safe and timely patient care
System improvement
Tracking population health
Quality improvement and assurance
Research and teaching
Clinicians who respond to indirect external information requests, and do not use Quick Release or Quick Disclosure workflows, should ensure that all related consent, request and response actions are appropriately documented in Connect Care.
All Connect Care patient information access is monitored for indicators of possible inappropriate access. Accordingly, those accessing information for approved indirect uses may want to document access in a way that does not clutter the patient record but still remains available to any future chart access audits.
A "chart access" record can be generated using a communication (letter) chart access form. No edits are required but additional explanatory comments can be added. Addressing the resulting "letter" to oneself (".ME") is recommended but the form can also be copied to a relevant health administration team or medical leader, as appropriate. The form will attach to the chart in the Chart Review "Letters" section and can be filtered for by using the "Reason for Letter" field.
Note that consent for or documentation of chart disclosure to patients is handled through the Consent & eForms Navigator where a "Consent to Disclose Health Information" digital form can be found.
Chart Access - Special Considerations
Some information disclosures merit special consideration, and information workflows, even though they relate directly to the services of a clinician in a patient's circle of care.
Disclosure of Harm
Disclosure of harm refers to a required process involving open discussions between a patient and healthcare providers about events leading to patient harm, the harm itself, and plans for future care. The associated patient and/or family conversations are both immediate and ongoing.
Immediate disclosure conversations should occur within 24 hours after a clinical adverse event (see AHS Disclosure of Harm Procedure) and be documented in the patient’s Connect Care record.
Ongoing disclosure discussions may be appropriate and should also be documented in Connect Care.
Documentation of disclosure should be completed by the person who leads the disclosure conversation (e.g., nurses, physicians, allied health, managers, leaders, or other clinicians). Other disclosure leads without the necessary documentation access should ensure that an enabled member of the disclosure team is assigned to document discussion(s).
Disclosure documentation can be inserted into a progress note using a SmartLink (".DISCLOSUREHARM"). A disclosure record can be quickly generated from any Letter Forms workflow (described above).
Reporting Adverse Events
It is important to report clinical adverse events using the “Reporting & Learning System for Patient Safety (RLS).” This is easily found by doing a chart (global) search for “RLS.”