- Email: [email protected]
Record Keeping
ADVICE TO MEMBERS
Record Keeping Always keep clear accurate contemporaneous notes which are legible, presentable, signed and dated. THIS advice is in keeping with and complementary to the Rules of Professional Conduct, particularly Rules 1, 2 and 3 (the Rules are set out in full in the Year Book which appears with the May issue of Physiotherapy). It is appropriate to highlight several words used in the introductory statement which demonstrate good practice. Clear: Meaning 'distinct and lucid', this would apply to style, layout and handwriting - a logical sequence of information and events which can be easily understood by other members of the health care team. This would normally include: 0 Name, address, date of birth or age, and sex of patient. 0 Referring agency - for those self-referred, whether GP notified and by whom, eg patient affirms that GP knows of attendance - necessary information if GP later complains that physiotherapist treated without his knoweldge. If patient asks that the GP should not be contacted and the physiotherapist decides to proceed with treatment, reasons for doing so should be noted. 0 Date of attendance - history assessment - aims and means of treatment (if not using problem oriented medical records) .All attendances dated and initialled or signed. Note any changes in condition or changes in approach of treatment and advice.
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Accurate: Meaning 'exact' and 'current', this means that neither subjective or judgemental statements should be made about the patient, eg 'neurotic'. However, you may wish to use subjective language as used by the patient, and this should be clearly indicated, or you may wish to comment on the patient's reaction to assessment or treatment that may explain the modality of physiotherapy used or advice given, eg manual as opposed to mechanical cervical traction. These last two points relate clearly to informed consent. Contemporaneous: 'Existing or happening at the same time' (PenguinEnglish Dictionary). Writing notes and comments must be seen as part of the management of a patient. Notes may be transcribed from rough to a physiotherapy card but this should be done w i t h i n a working day, otherwise interpretation errors could creep in. When recording an incident this must be done immediately, on the appropriate form if necessary and/or in the patient's physiotherapy records. If time is allowed to elapse before doing this, ie the accident form is dated eight or more hours after the incident occurs, this would render them invalid in a court of law. Legible: Notes should be typed if ,possible. However, most records are handwritten. These must be legible and in permanent ink. Correction fluid should not be used. If a change is made, cross out the mistake and initial it (as with a mistake made on a cheque). Remember that word processor notes are not eligible in court as they may be altered without any trace. It is therefore wise to take a detailed and/or complex assessment down in rough and transfer the details in a logical and legible fashion to the
physiotherapy card (within one working day). Presentable: A clear layout and format as mentioned above is essential. Problem oriented medical records (POMR) gives such a logical framework and are being used increasingly widely around the country. Make sure the card is appropriate in size and detail t o allow a clear and logical presentation of the facts relevant to the patient, their condition and the management of both. Signed and dated: All patient attendances, non-attendances and refusals of treatment and advice must be noted. It is imperative that the physiotherapist(s1 dealing with a particular patient on a specific day can be identified; this means that either on the card or in a register the patient's attendance is dated and signed. It is therefore important that the superintendent holds a record of the signatures of the physiotherapyStaff moving through the department over the years. Transfer to other physiotherapists - a physiotherapist receiving a patient from another physiotherapist will need to reassess and set goals and objectives with the patient prior to proceeding with the management of that patient. The information contained within this article and more detailed advice relating to the legal implications of record keeping will appear shortly as a factsheet from the Professional Affairs Department. REFERENCES Problem Orientated Medical Records (POMR): Guide lines for therapists, by D Kirk, A Parsons, M Scholey and L Wakeling, 1988. Available from the King's Fund Centre, 126 Albert Street, London NW1 7NF.
Handling Loads at Work: Proposals for Regulations and Guidance This is a consultative document, issued by the Health and Safety Commission, which sets out proposals designed to reduce the toll of injuries at work associated with manual handling. The Handling of Loads Regulations will replace a number of earlier provisions on lifting of heavy loads contained in various Acts and regulations. The duties in the regulations are placed on the employers in relation to their employees, and on the self-employed in relation t o themselves; also on the employees who must take reasonable care for their own health and co-operate with their employer's efforts t o comply with the regulations. The guide sets out main principles to follow and does not attempt to deal in detail with the wide range of handling activities. It states that any reference to handling a load includes reference to handling a person, and the word handling is taken to mean lifting, lowering, carrying, pushing, etc, by hand and/or bodily forces. The regulations are short and straightforward and state that employers must
92
make an assessment of handling operations and take necessary steps to prevent reasonable and foreseeable injury. Assessment is then discussed under the headings of task, load, equipment, environment, individual's characteristics and the need for personnel selection and the role of instruction. It states how these are all interrelated and cannot be considered in isolation. It emphasises the importance of welldesigned systems of work and affirms that training in handling is only likely to be effective as a complement to this and not as a substitute. It stresses the dangers of prolonged and frequent lifting, awkward postures as well as heavy loads. It emphasises the importance of minimising lifting, reducing loads, using mechanical aids, the importance of working levels, of work organisation including job rotation so avoiding repetitive work, and, finally, it provides a check list for employers. The contents of this document are based upon sound ergonomic principles and will be particularly welcomed by physiotherapists
working in occupational health and preventive medicine related t o musculoskeletal disorders, as it echoes the opinions and experience gathered by therapists working in this field. This is an important document and should be read by all physiotherapists concerned with this topic as well as by students of architecture and design in order that working, environments may be fitted to man rather than man to his environment. Comments are welcomed and should be sent to Mr R H M Beveridge, Safety Policy Division B1, Health and Safety Executive, Baynards House, 1 Chepstow Place, Westbourne Grove, London W2 4TF by March 1, 1989.
JILL McCAY MCSP ONC
Available from Sir Robert Jones Memorial Workshop, Units 3 & 5 - 9, Grain Industrial Estate, Harlow Street, Liverpool L8 4UTH.
Physiotherapy, Februaw 1989, vol75, no 2
Record Keeping Always keep clear accurate contemporaneous notes which are legible, presentable, signed and dated. THIS advice is in keeping with and complementary to the Rules of Professional Conduct, particularly Rules 1, 2 and 3 (the Rules are set out in full in the Year Book which appears with the May issue of Physiotherapy). It is appropriate to highlight several words used in the introductory statement which demonstrate good practice. Clear: Meaning 'distinct and lucid', this would apply to style, layout and handwriting - a logical sequence of information and events which can be easily understood by other members of the health care team. This would normally include: 0 Name, address, date of birth or age, and sex of patient. 0 Referring agency - for those self-referred, whether GP notified and by whom, eg patient affirms that GP knows of attendance - necessary information if GP later complains that physiotherapist treated without his knoweldge. If patient asks that the GP should not be contacted and the physiotherapist decides to proceed with treatment, reasons for doing so should be noted. 0 Date of attendance - history assessment - aims and means of treatment (if not using problem oriented medical records) .All attendances dated and initialled or signed. Note any changes in condition or changes in approach of treatment and advice.
-
Accurate: Meaning 'exact' and 'current', this means that neither subjective or judgemental statements should be made about the patient, eg 'neurotic'. However, you may wish to use subjective language as used by the patient, and this should be clearly indicated, or you may wish to comment on the patient's reaction to assessment or treatment that may explain the modality of physiotherapy used or advice given, eg manual as opposed to mechanical cervical traction. These last two points relate clearly to informed consent. Contemporaneous: 'Existing or happening at the same time' (PenguinEnglish Dictionary). Writing notes and comments must be seen as part of the management of a patient. Notes may be transcribed from rough to a physiotherapy card but this should be done w i t h i n a working day, otherwise interpretation errors could creep in. When recording an incident this must be done immediately, on the appropriate form if necessary and/or in the patient's physiotherapy records. If time is allowed to elapse before doing this, ie the accident form is dated eight or more hours after the incident occurs, this would render them invalid in a court of law. Legible: Notes should be typed if ,possible. However, most records are handwritten. These must be legible and in permanent ink. Correction fluid should not be used. If a change is made, cross out the mistake and initial it (as with a mistake made on a cheque). Remember that word processor notes are not eligible in court as they may be altered without any trace. It is therefore wise to take a detailed and/or complex assessment down in rough and transfer the details in a logical and legible fashion to the
physiotherapy card (within one working day). Presentable: A clear layout and format as mentioned above is essential. Problem oriented medical records (POMR) gives such a logical framework and are being used increasingly widely around the country. Make sure the card is appropriate in size and detail t o allow a clear and logical presentation of the facts relevant to the patient, their condition and the management of both. Signed and dated: All patient attendances, non-attendances and refusals of treatment and advice must be noted. It is imperative that the physiotherapist(s1 dealing with a particular patient on a specific day can be identified; this means that either on the card or in a register the patient's attendance is dated and signed. It is therefore important that the superintendent holds a record of the signatures of the physiotherapyStaff moving through the department over the years. Transfer to other physiotherapists - a physiotherapist receiving a patient from another physiotherapist will need to reassess and set goals and objectives with the patient prior to proceeding with the management of that patient. The information contained within this article and more detailed advice relating to the legal implications of record keeping will appear shortly as a factsheet from the Professional Affairs Department. REFERENCES Problem Orientated Medical Records (POMR): Guide lines for therapists, by D Kirk, A Parsons, M Scholey and L Wakeling, 1988. Available from the King's Fund Centre, 126 Albert Street, London NW1 7NF.
Handling Loads at Work: Proposals for Regulations and Guidance This is a consultative document, issued by the Health and Safety Commission, which sets out proposals designed to reduce the toll of injuries at work associated with manual handling. The Handling of Loads Regulations will replace a number of earlier provisions on lifting of heavy loads contained in various Acts and regulations. The duties in the regulations are placed on the employers in relation to their employees, and on the self-employed in relation t o themselves; also on the employees who must take reasonable care for their own health and co-operate with their employer's efforts t o comply with the regulations. The guide sets out main principles to follow and does not attempt to deal in detail with the wide range of handling activities. It states that any reference to handling a load includes reference to handling a person, and the word handling is taken to mean lifting, lowering, carrying, pushing, etc, by hand and/or bodily forces. The regulations are short and straightforward and state that employers must
92
make an assessment of handling operations and take necessary steps to prevent reasonable and foreseeable injury. Assessment is then discussed under the headings of task, load, equipment, environment, individual's characteristics and the need for personnel selection and the role of instruction. It states how these are all interrelated and cannot be considered in isolation. It emphasises the importance of welldesigned systems of work and affirms that training in handling is only likely to be effective as a complement to this and not as a substitute. It stresses the dangers of prolonged and frequent lifting, awkward postures as well as heavy loads. It emphasises the importance of minimising lifting, reducing loads, using mechanical aids, the importance of working levels, of work organisation including job rotation so avoiding repetitive work, and, finally, it provides a check list for employers. The contents of this document are based upon sound ergonomic principles and will be particularly welcomed by physiotherapists
working in occupational health and preventive medicine related t o musculoskeletal disorders, as it echoes the opinions and experience gathered by therapists working in this field. This is an important document and should be read by all physiotherapists concerned with this topic as well as by students of architecture and design in order that working, environments may be fitted to man rather than man to his environment. Comments are welcomed and should be sent to Mr R H M Beveridge, Safety Policy Division B1, Health and Safety Executive, Baynards House, 1 Chepstow Place, Westbourne Grove, London W2 4TF by March 1, 1989.
JILL McCAY MCSP ONC
Available from Sir Robert Jones Memorial Workshop, Units 3 & 5 - 9, Grain Industrial Estate, Harlow Street, Liverpool L8 4UTH.
Physiotherapy, Februaw 1989, vol75, no 2