Clinical Records and Reports in Physiotherapy PDF

TOPIC 4: CLINICAL RECORDS AND REPORTS IN PHYSIOTHERAPY Medical records A chronological written account of a patient’s examination and treatment that includes the patient’s medical history and complaints. Physical therapy records management Keeping Storage Retrieval Disposal Patient rights: legal pro...

TOPIC 4: CLINICAL RECORDS AND REPORTS IN PHYSIOTHERAPY Medical records A chronological written account of a patient’s examination and treatment that includes the patient’s medical history and complaints. Physical therapy records management Keeping Storage Retrieval Disposal Patient rights: legal protection Legally the right to health protection is regulated. Principles of dignity and individual freedom. -Guarantee confidentiality -Avoid discrimination Each country develops laws and rules to protect these rights and obligations. Clinical records in PT Necessary to keep a clinical record for: clinical purpose, scientific research or legal purpose. Important for: PT assistance and legal point of view. Purposes of clinical records To provide an accurate and comprehensive account of patient care with clear treatment plans and relevant interventions. To record the chronology of events, problems that arise, and response to them. Written evidence of health service to keep record and guarantee continuity of care between professionals. To meet legal , professional requirements. Clinical records Must be: accurate, legible, permanent, confidential. Has to be maintained for each patient so it can be easily: -read -retrieved -copied -printed Identification that is unique to each patient must appear on every page of that patient’s clinical record. All entries in a clinical record must be chronological, record the date of the entry, and identify the physical therapist making the entry. Clinical records should contain Record identification number Key demographic data such as full name, NHI number, date of birth, gender, ethnicity, contact details. Identification details of the workplace. The date Any relevant family or personal history Analysis of the patient’s signs and symptoms. Treatment plan all procedures and the date and time they took place. Progress made and discharge plan Information given to the patient Reports from referring health professionals Name, signature and of the PT responsible Electronic health records Records in in a structured digital format Softwares systems for general practitioners for PT. - Generally accepted best way to store the patient’s medical data. Clinical reports in Physiotherapy Communication between people involved in th patient health issues: -Medical-legal report -Assessment/Diagnostic report -Status