Best Practices in Patient-Centred Clinical Documentation

Course Description

Welcome to the Best Practices in Patient-Centred Clinical Documentation course. This eLearning course is intended for Health Care Providers who document patient care in Island Health’s Electronic Health Record (EHR).

This course will take you approximately 30 minutes to complete.

Purpose

As patients become more involved as partners in care and health, Island Health supports patient empowerment through direct access to their clinical information. The MyHealth patient portal is expanding to include clinical documentation. Medical staff members and clinicians are encouraged to understand a patient’s right to access their information and become more aware of best practices for clinical documentation. Clinical documentation is founded on the principles of comprehensiveness, timeliness, accuracy and quality. Through this education, these principles will be reviewed in the context of a patient-centred framework facilitated through safe and inclusive language.

Learning Outcomes

At the end of this course you will be able to:

• Recognize inclusive, culturally safe, and person-first language as a best practice standard for clinical documentation.
• Identify sensitive information that cannot be published to Island Health’s MyHealth patient portal.
• Recognize the Electronic Health Record (EHR) naming convention for document types that can be released to patients through the MyHealth patient portal.