Chart Access and Disclosure Forms
Chart Access forms can help with documentation of information access and disclosures, chart review for quality or safety purposes or other activities that may need to be formally declared, with possible notices to interested parties.
Chart Access
The Connect Care Clinical Information Sharing Approach (CISA) principles guide how health data is collected, accessed, used, disclosed and exchanged in the Connect Care clinical information system. While patient charts should only be accessed by clinicians in a patient's circle of care, the CISA norms and Alberta Health Information Act (HIA) additionally support information access for functions that support patient care less directly. These include:
Promoting safe and timely patient care
System improvement
Tracking population health
Quality improvement and assurance
Responding to patient complaints and investigations
Research and teaching
All Connect Care patient information access is monitored for indicators of possible inappropriate access. Accordingly, those accessing information for approved secondary uses may want to document access in a way that does not clutter the patient record but remains available to any future chart access audit.
Documenting Chart Access for Secondary Use
A "chart access" form can be generated using Communication workflows (cForms). There are variants for general secondary use cases as well as a form intended specifically for chart access while responding to patient complaints. The forms can be sent to requesting organizations, administrators, medical leaders and oneself (".ME" as addressee).
Clinicians may be required to find and release specific information from a patient's chart as part of an investigation. Disclosure or release of information is further documented with a "Quick Release" tool (see Disclosure Documentation), embedded within the Chart Access letter forms.
A completed and signed chart access form automatically attaches to the patient chart in the Chart Review "Letters" section and can be filtered for by using the "Reason for Letter" field ("Chart Access").
Providing User or Technical Support
Some Connect Care users may serve in "Super User", "Trainer", "Builder" or other defined roles that require Connect Care chart access in order to replicate problems, investigate solutions, test build, generate reports or otherwise support the safe and effective use of Connect Care. Such users are typically provided with a supplemental non-clinical role, or "job", that can be selected at logon as needed (e.g., "Clinical Informatics", "Builder", "Reporting User", etc.). The non-clinical role should be used when patient chart content could be exposed during tasks unrelated to direct patient care. If such a role is available, and used, then chart access audit logs will reflect this and there is no need for the information access or release workflows described above.
Disclosure of Harm
A "disclosure of harm" Chart Access form can also be generated under this category. The workflow is the same, facilitating Connect Care disclosure of harm best practices.
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.