Field Documentation and SOAP Notes PDF

Field Documentation But first EAP Recap What is it? Why do we need to create this? What does it need to include? Documentation A point in valid informed consent A point in reducing risk of litigation A significant part of your professional life! Purpose of Documentation 1. To record care gi...

Field Documentation But first EAP Recap What is it? Why do we need to create this? What does it need to include? Documentation A point in valid informed consent A point in reducing risk of litigation A significant part of your professional life! Purpose of Documentation 1. To record care given (and supporting evidence as to why) which protects both the therapist and the patient, should any questions arise as to the care the patient received. Medical records are considered legal documents and are subject to subpoena in case of medical legal investigations. Should you be called to court for any reason, your record will support what you saw, heard, and did at the scene of the emergency Purpose cont. 2. Communicate to other health care professionals all the information the therapist obtained while treating a patient. 3. Reference for yourself as to previous findings, see progressions/regressions. Point of reference. Documentation Critical from a/an ___________ perspective: Ethical Legal Professional Why SOAP? Standardized medical format Considered a legal document and may not be altered. i.e. no erasing. You may add to notes but you may not change notes. Written in pen and signed at the end of each entry A way to organize assessment information that is universally understood by medical professionals What is SOAP? Subjective Objective Analysis (What is the problem?) Plan (What are you going to do about it?) Examples of Subjective findings: Chief complaint MOI Events leading up to injury Pain Previous injury information Information the athlete provides Examples of Objective findings: Swelling Heat Redness Range of motion Strength Palpations Things that you observe or measure Important to note…  One of the greatest risks to exposed liability is not what a record contains but what is omitted. Lack of information can be interpreted as a test not performed, a measurement not taken, etc. Analysis Consider your subjective and objective information Analysis is your index of suspicion, or what you think the condition may be Analysis must reflect your findings This will determine your actions Plan Should clearly indicate your immediate actions Also future plans Referral Suggested follow up Example of Plan Applied pier principle (provide parameters) Educated on pier principle (provide parameters) Requested physician follow up Provided athlete and parents with injury information – specifically… what did you tell them? What advice did you give? Sample Scenarios You run on to the field after witnessing opponent tackle your player, low on the leg. Your player dropped to the ground immediately and is screaming with pain. As you approach, you see that the lower leg is resting at an awkward angle. Athlete reports hearing a crack, pain is rated as 10/10, doesn’t want to move the limb, pain is sharp and throbbing. Distal pulse is present. No open lesions visible. Athlete has an inhaler and has had several ankle sprains, never had a fracture. What might you anticipate being your “A” What might you anticipate being your “P” Concussion/C-spine http://www.youtube.com/watch?v=KJh3kKV3 gMI You witness your athlete receive a severe blow to the head. Your athlete drops to the ice, helmet coming off. The athlete remains still on the ice as you approach. As you get to the athlete you can see that eyes are closed. You do not see blood anywhere. Athlete does not respond to verbal stimuli. Athlete is breathing and heart rate is 120 bpm. You immobilize the athlete and request collar and board. Blood pressure is 130/90. Athlete responds to verbal stimuli after 2 minutes. Reports a severe headache and dizziness. Athlete complains of pain with tracking. Pupils are equal and reactive. What might you anticipate being your “A” What might you anticipate being your “P” You are covering a soccer game. You get called to a group of boys behind the stands. One boy is on the ground holding his arm. He tells you his shoulder has popped out. Distal pulse is present. He is unwilling to move arm. Appears pale and clammy. He tells you this has happened before. His last meal was 2 hours ago, he has no allergies, is on no meds. His mother is at work about 10 minutes away. You stabilize the shoulder with a tensor and swath and a friend calls the boys mother. What might you anticipate being your “A” What might you anticipate being your “P” When to Document? Any time that you give medical care to someone Or medical advice… you should be able to show why you made the decisions that you did. Formatted as a SOAP note Other times to document? If someone refuses your care. Confrontational situations/disagreeme nt in medical advice A paragraph or narrative may be necessary for these types situations as they are not assessments How to keep records confidential? Use codes Keep personal information in safe location Don’t leave your logbook lying around Retaining documents Maintain all documents in a safe and secure location Documents must be kept for 10 years after the date of the last entry For minors, documents must be kept for 10 years after the athlete reaches the age of 18  (Public Hospitals Act, Regulation 965, section 20(3) Summary To record the care given and the supporting evidence as to why that care was given. This protects the therapist and the patient. This is our primary reason at this point. To communicate with other health care professionals. For your own reference wrt progressions/regressions, etc. Use standard medical documentation style – SOAP Subjective, objective, analysis, plan