Embedded Files
Forms and Requests
Forms and Requests
All forms/request sheets relating to employment or administration matters are available in the forms section of this manual.
Forms are to be completed as required and will be kept on file.
Forms and request documents can be found in "Clinic Forms"
Memos
Memos
Periodic memos will be provided to employees. It is the employee’s responsibility to read the memos and understand its contents. Memos requesting information and/or action should be responded to in a timely manner.
Charting
Charting
Physiotherapists are bound by professional and legal standards relating to the documentation of patient records.
Good clinical records are the cornerstones of the practice. They are essential for the protection of the interests of the practitioner and the patient. Good records will demonstrate the success of physiotherapy treatment both to referrers and to third party payers.
Every patient who attends this practice has a clinical record. Please be aware that records can be the subject of a court subpoena or a search warrant. If records are involved in a court action, they need to be accurate and unaltered.
For all new patients the following routine data is collected:
- Patient’s full name and address
- Telephone number at home and at work
- Emergency contact number
- Date of birth
- Gender
- Occupation / type of work / sport or leisure interest
- Details of private health fund
- Details of workers compensation or motor accident claims
- Name of referrer
- For non-referred patients, usual medical practitioner
- How the patient found out about your service
- Dates of service
Returning patients should have the routine data updated.
Clinical records remain the property of Goldfields Physio. When accessing clinical records offsite ensure that you are not using a public network as this may result in data compromise. Loss or theft of records is very serious and may result in disciplinary action.
The following outlines the minimum standard expected with patient records in relationship to physiotherapy service documentation.
INITIAL ASSESSMENT
INITIAL ASSESSMENT
A complete subjective history is required including:
- Presenting problem/complaint (SINS)
- Timeframe (i.e. when it started)
- Status since onset
- Aggravating factors
- Easing factors
- Medication
- PMH / general health / medical and surgical history
- Relevant mandatory questions
- Occupation and current work status
A complete objective or reason why it has not been completed including:
- Observation
- ROM (active movement as minimum)
- Resisted / Strength (peripheral)
- Neural / Dural / Reflexes (as indicated in spinal)
- Palpation
- Special Tests
Initial interpretation (i.e. impression)
Treatment
- What you did and where and how you did it
- Response to treatment must be documented (i.e. objective asterisk signs reassessment)
Plan for treatment
CONTINUATION RECORDS
CONTINUATION RECORDS
Relevant subjective history, which should include:
- Response to last intervention
- Alterations in presentation (pain, function, etc)
- Change in status (work, activity, etc)
A re-evaluation of your key asterisks signs:
- Observation
- ROM (active movement as minimum)
- Resisted / Strength (peripheral)
- Neural / Dural / Reflexes (as indicated in spinal)
- Palpation
- Special Tests
Treatment
- What you did and where and how you did it
- Home exercises should be captured via photo and the program uploaded to Nookal
- Response to treatment must be documented (i.e. objective asterisk sign reassessment)
Plan for treatment
Emails, Reports & Other Communications
Emails, Reports & Other Communications
All communication had in relation to a client should be retained on their clinical record. This includes outcome measures, phone conversations, reports and requests, treatment management plans, email communication.
Chart Audits
Chart Audits
Regular audits occur to ensure compliance with the above noted charting requirements.
Physiotherapist will be provided with a record of the audit and corrective action is expected for any issues identified in the review. Non-compliance of charting standards will be considered a serious breach of professional standards.
Disposal of clinical records
Disposal of clinical records
Retention of records comes under the various Limitation Acts in States and in Federal government area which restrict action after a particular period.
For example, if a contract has been breached, then action must be brought within a specific period – usually seven years, although it may vary under certain circumstances to twelve years or more.
This suggests that perhaps records have to be retained for a minimum period of seven years after patient treatment ceases in the case of adults. In the case of minors, records should be retained until the minor reaches the age of 25.
Although it is not illegal, destroying records within seven years of treating could be interpreted as a breach of the duty of care or of the physiotherapist / patient contract.
Clinical Records of patients must not be destroyed without the authorization of a principal of the practice.
When it is authorized for records to be destroyed, they should be completely destroyed by shredding
Release of clinical records
Release of clinical records
Clinical records are confidential documents. It is therefore expected that private matter be kept private and that records are kept securely.
Any request to release physiotherapy patient clinical records must be authorized by the patient in writing. The signed authorization form is filed in the history (see forms)
All physiotherapy clinical records that are photocopied must have the date on the sheet(s) involved.
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