Patient Health Records Overview

Patient's Health Record

• A patient's health record is a detailed written account of their health history and care journey
• It includes health history, health goals, details of each encounter, outcomes, and prognosis.

Importance of Patient's Health Record

• Acts as a communication tool for other healthcare providers.
• Allows tracking of patient progress and adjustment of care.
• Helps determine future care needs.
• Serves as a memory aid for healthcare professionals managing many patients.

Objectives of Record-Keeping

• Facilitates quality patient care by documenting events and knowledge history.
• Ensures access to accurate information about a patient's health.
• Ensures continuity of care from different healthcare professionals.
• Maintains accountability to patients, clients, payors, healthcare providers and professional organizations
• Demonstrates professional judgment, reasoning and adherence to practice standards.
• Meets organizational and legal requirements.

Principles of Recording Keeping

• Identifiable
• Legible and understandable (grammatically correct)
• Comprehensive (easy to understand)
• Accurate (timely recording, generally within 2 hours)
• Accessible and retrievable
• Secure and confidential

Kinesiologist's Role in Record Keeping

• Every part of the record has a unique identifier (e.g., hospital number, date of birth).
• Records should be sequential (e.g., chronologically).
• Every entry should be dated and signed.
• Changes to records should be clearly indicated, and the original record retained.
• Information recorded should be legible.
• Information should be entered within a reasonable timeframe (ASAP or within 24 hours).
• Appropriate language should be used.
• An audit trial should be maintained.

Information to Record

• Demographics (date of birth, address).
• Primary physicians and referring professionals.
• Reason for referral.
• Date, purpose, and mode of contact.
• Chief complaints or concerns and supporting data.
• Past health, family, and social history.
• Records of imaging and reports from other healthcare professionals.
• Appointment cancellations and reasons.
• Examinations, assessments, tests, impressions, treatments, and who performed them.
• Informed consent details and recommendations.
• Referrals to other health professionals.
• Any controlled acts performed.
• Any procedures that were commenced but not completed or refused and the reasons why.
• Perceived or potential conflicts of interest.
• Abbreviations used, and the discharge of the patient.
• Consent and discussion details.
• Health history, assessment results, and interpretations.
• Treatment provided and patient response.
• Referral to other professionals.

Patient Record Retention

• Records are to be kept for at least 10 years if the patient is 18 or older.
• If the patient is below 18 years of age, the record is to be retained for a period of at least 10 years after the patient reaches 18 years of age or the last contact.

Record Destruction

• Records must be destroyed securely using a method that prevents retrieval.

SJHC 'Clinical Documentation' Standard

• Documentation must be complete, accurate, legible, and timely.
• Completed by healthcare professional, including signature and date.
• Uniquely identify the patient and avoid value judgments.
• Indicate corrections by crossing out, re-writing the correct information, and stating “mistaken entry” and the reason.

ACSM 5-Step Approach

• Screening
• Medical history
• Fitness assessment
• Special considerations
• Care plan

Exercise Related Complications

• Musculoskeletal injuries are the most common.
• Risks of musculoskeletal injuries and cardiovascular complications tend to be lower with higher physical fitness

Cardiovascular Events

• Less common than musculoskeletal injuries but can lead to long-term morbidity and higher risk of mortality.
• Heart attack risk increases significantly during periods of re-entry into vigorous exercise after a period of inactivity.
• Risk inversely related to physical fitness

ACSM Pre-Participation Screening Algorithm

• Based on current physical activity levels.
• Accounts for signs of cardiovascular, metabolic, or renal disease.
• Includes planned physical activity intensity.
• Emphasises medical clearance when necessary.

Step 1 of ACSM Pre-Participation Screening Algorithm

• The individual should be checked for having regularly engaged in physical activities (30 minutes or more physical activity every 3 days for the past 3 months).

Step 2 of ACSM Pre-Participation Screening Algorithm

• Assess if the individual has any diseases present, or signs of disease. Risk factors include: hypertension; metabolic/ type 1 or 2 diabetes; renal issues (renal disease, poor appetite, swelling (in lower body); angina (chest pain); shortness of breath; feeling lightheaded; breaking out in cold sweats; sickness to the stomach.

Step 3 of ACSM Pre-Participation Screening Algorithm

• Establish the individual's exercise intensity planned for their workouts. This intensity may result in a slight increase in breathing and heart rate, allowing for conversations.

Rate of Perceived Exertion (RPE) Scale

• Used for ascertaining workout intensity.
• RPE 6 (resting), RPE 20 (maximal exertion). Moderate to vigorous intensity lies between RPE 12-15.

Submaximum CRF tests

• Use heart rate and breathing to determine activity intensity in submaximum testing.
• Typically 70% of heart rate reserve (HRR) or 85% of predicted maximum heart rate (HR max) .

Other considerations for Exercise Testing

• Ensure adequate cool-down and recovery time.
• Monitor symptoms throughout testing
• Stop testing if signs of discomfort or distress are present.