Ethics in Documentation PDF

Ethics in Documentation Dr. Mohammed Essam Lecturer of Physical Therapy for integumentary system Disorders and burn  What is documentation?  Anything written or printed.  Relied on as a record of proof for authorized persons.  Medical documentation (doctors author record) me...

Ethics in Documentation Dr. Mohammed Essam Lecturer of Physical Therapy for integumentary system Disorders and burn  What is documentation?  Anything written or printed.  Relied on as a record of proof for authorized persons.  Medical documentation (doctors author record) means a statement from licensed physician or other appropriate practitioner providing information.  Introduction  Health records are essential for the provision of quality health care services and support enhanced outcomes for health consumers.  Health records include all forms of documentation irrespective of the medium, i.e. paper or electronic, held by private practices or organizations.  Importance of Documentation Patient health record is important for the following reasons: 1) To ensure patient safety. 2) To provide continuity of care. 3) To provide a standardized way of communicating between physiotherapists and other health professionals. 4) To provide an accurate record for the care the patient received. As it provide vital information during investigation.  Creation and content of health record  Patients should feel confident that their health information will be recorded with their appropriate informed consent, respectfully, with regard to their cultural needs, and be kept confidential (except where legally required to do otherwise).  Health Records Contents  Key demographic data such as full  Medications. name, NHI number, date of birth,  Comprehensive subjective and gender, contact details, residency objective assessment. status and name of Practitioner.  Relevant outcome measurements.  The date and time.  Patient goals and management plan.  The principal/primary diagnosis.  Information given to the patient.  Relevant family history.  Record of consent given or refused.  Health Records Contents  Analysis of patient’s signs and symptoms.  Progress made and discharge plan.  All treatment and other interventions,  Note of risks and/or problems that have with the date they took place. arisen and the action taken to rectify  Letters and reports to, or from, referring them. health professionals or other involved  Electronic authentication or printed name, parties, and any clinical photographs signature and designation of the and/or digital images, should be dated. physiotherapist responsible.  Health Records Contents  Information must be added to patient records after every physiotherapy encounter, including when the patient contacts the physiotherapist by telephone or other means, does not attend, or another person contacts the physiotherapist about the patient or on the patient’s behalf.  Health Records Contents  Receipt of reports (diagnostic procedures, letters from other professionals) should be acknowledged or electronically recorded and stored with the patient records. The use of ‘copy and paste’ or ‘auto-population’ as a method of documenting in an electronic system is discouraged. Each patient record is unique, and patient records must be verified and updated accordingly.  Guidelines for physical therapy documentation  Physical therapy examination, evaluation, diagnosis, prognosis, and plan of care shall be documented, dated, and authenticate by the therapist who performs the service.  APTA defines a "guideline" as a statement of advice.  Authentication is the process used to verify that an entry is complete, accurate and final.  Completion of the initial examination/ evaluation is typically completed in one visit, but may occur over more than one visit. Documentation elements for the initial examination/evaluation  Examination: Includes data obtained from the history, systems review, and tests and measures.  Evaluation: It may include documentation of the assessment of the data collected in the examination and identification of problems pertinent to patient management.  Diagnosis: Indicates level of impairment, activity limitation and participation restriction determined by the physical therapist.  Documentation elements for the initial examination/evaluation  Prognosis: Provides the predicted level of improvement that might be attained through intervention and the amount of time required to reach that level.  Plan of care: Includes goals, interventions planned, proposed frequency and duration, and discharge plans.  General Guidelines  Documentation is required for every visit.  All documentation must comply with the regulatory requirements.  All handwritten entries shall be made in ink and will include original signatures.  Electronic entries are made with appropriate security and confidentiality provisions.  Charting errors should be corrected by drawing a single line through the error and initialing and dating the chart or through the appropriate mechanism for electronic.  Documentation that clearly indicates that a change was made without deletion of the original record.  Informed Consent  PT has responsibility for providing information to pt. and for obtaining pt.’s informed consent before initiating PT.  These deemed competent to give consent are competent adults. The information provided to patient  Clear description of TTT ordered.  Material’s risks associated with TTT.  Expected benefits of TTT.  Reasonable alternatives to recommended TTT.