Chart Access and Disclosure Forms
Chart Access forms can help with documentation of information disclosures, chart review for quality or safety purposes or other activities that should be formally recorded, with possible notices to interested parties.
Chart Access
The Clinical Information Sharing Approach (CISA) outlines 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 their circle of care, the CISA additionally supports information access for functions supporting patient care less directly. These include:
Promoting safe and timely patient care
System improvement
Tracking population health
Quality improvement and assurance
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 still remains available to any future chart access audits.
A "chart access" form can be generated using cForms as described above. No edits are required but additional explanatory comments can be added. Addressing the 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.
Information Disclosure
A "disclosure of harm" 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.