Guidelines for allied health assistants documenting in ...

1 Queensland health Guidelines for allied health assistants documenting in health records allied health Professions Office of Queensland Revised December 2019 Guidelines for allied health assistants document ing in health records Published by the State of Queensla nd (Queensla nd health ), December 2019 This document is licensed under a Creativ e Commons Attrib ution Australia licence. To vie w a copy of this licence, vis it cre ativ icenses/ State of Queensla nd (Queensla nd health ) 2019 You are free to copy, communic ate and adapt the work, as lo ng as you attribute the State of Queensla nd (Queensla nd health ). For more in formation contact: allied health Professio ns Office of Queensla nd, Department of health , GPO Box 48, Brisbane QLD 4001, email Allied_Health . , phone (0 7) 332 89298. An electronic version of this document is available at . Disclaimer: The content presented in this publication is dist ributed by the Queensland Government as an information source only.

2 The State of Queensl and makes no statements, representations or warranties about the accuracy, completeness or rel iability of any information contained in this publication. The State of Queensland disclaims all responsibility and all liability (including without limitation for liability in negligence) for all expenses, loss es, damages and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any reason rel iance was placed on such information. Guidelines for allied health assistants documenting in health records allied health Professions Office of Queensland - i - Contents Introduction .. 1 Prerequisite information .. 1 Why document? .. 2 What information needs to be docu mented? .. 2 Principles of documentation .. 3 Documentation standard 4 Al ternative documentation formats .. 5 SOAP .. 5 SBAR .. 5 El ectronic health re co rds .. 5 Mi sco nduct .. 6 Appendix 1a: Assessment of competency.

3 7 Appendix 1b: Knowle dge check .. 8 Appendix 1c: health re cord audit .. 9 Appendix 2: Commonly used abbreviations .. 10 Appendix 3: Documentation template examples .. 11 Appendix 4: Example scenarios .. 13 Appendix 5: Practice scenarios .. 18 Appendix 6: SOAP format .. 22 Glossary .. 24 Guidelines for allied health assistants documenting in health records allied health Professions Office of Queensland - ii - Guidelines for allied health assistants documenting in health records allied health Professions Office of Queensland - 1 - Introduction These guid eli nes have been develo ped to facilitate the tra in ing of allied health assistants (AHAs) in documentation for Queensla nd health purposes. It is recommended that you clarify and discuss the content with your supervi sor. On completion of this tra in in g, AHAs should : understand the purp ose of documentation know what should be documented know what to inclu de in health record entries be confid ent about when and how to document apply appropriate documentation standards.

4 Your supervisor or manager will assess your competency in documentation once you have completed both the theoretical and practical ele ments of the train in g outlined in Appendix 1a. Once deemed competent, there is no further requirement for the supervi sing allied health professional to countersign AHA entries. Please note: Depending on the clinical settin g, health records may be synonymously referred to as patie nt chart s, cli ent files, medical record s, etc. To ensure consistency, the term health record will be used throughout this document. Prerequisite information You will need to complete the following train ing modules within fiv e days of commencement. They can be accessed online at clinical documentation clinical handover informed consent. Prior to commencing tra ining on documentin g in health record s, it is esse nti al that you have a clear understandin g of the concepts of privacy, confid entia lity and consent as they re late to healthcare.

5 Patient/c li ent information is confidentia l and the precautions below should be followed to ensure that all documented information remains confidential: do not allow anyone to touch or lo ok at a health record unless they are a healthcare pro vid er involv ed in the care of that patie nt keep all patie nt re cords in a safe and secure place do not tell anyone about what is in a health record unless they are takin g care of the person. Please note: The obligati on to re spect the confid entia li ty and priv acy of patie nt/client in formation contin ues after employees have left Queensla nd health emplo yment. Guidelines for allied health assistants documenting in health records allied health Professions Office of Queensland - 2 - Queensla nd health is subject to the following privacy and confid enti ality le gis lation, which set the standards for how pers onal in formati on is handled: Information Privacy Act 2009 Information Priv acy Regulation 2009 Hospital and health Boards Act 2011(Part 7) Hospital and health Boards Regulation 2012.

6 Additio nal in formation on health records and privacy is avail able at: Queensla nd health employees are also required to comply with the standards of confid enti ali ty and privacy as specif ied in the Code of Conduct for the Queensla nd Public Service available at: To learn more about consent, ple ase refer to: Guide to informed decis ion-making in healt hcare availa ble at: . Why document? Documentation is essential to maintain safe, hig h quality care. It is used: as a communication tool to facilitate the contin uum of patie nt/client care to allow evalu ation of the care provid ed for research or epid emio lo gical needs to meet statutory requir ements in case the in formation is required for medic o-le gal defense. What information needs to be documented? You need to document significant aspects of patie nt/client care inclu din g: all direct contact with the patie nt/client, carers or other re lated in div id uals other sig nificant activ ity that re lates to patient/client care (inclu ding in direct contact), for example, missed or cancelled appoint ments, information pro vi ded/posted to the patie nt/client.

7 Guidelines for allied health assistants documenting in health records allied health Professions Office of Queensland - 3 - Principles of documentation The format of your entries will be guid ed by Hospital and health Servi ce (HHS) policy as well as discip line and work unit-specific practices. Regardless of the format, the followin g princip les of documentation apply : always document as soon as possib le after the in tervention ( occasion of servi ce, phone call) content should be concis e, re le vant, appro priate and accurate do not dia gnose use only standard abbreviations and avoid non-standard termin olo gy it is im port ant that your documentation can be understood by anyone re ading the health record check with your supervisor regard in g which abbreviations you can use if you don t re cognise abbreviations you see in other entries, ask your supervisor or another alli ed health professio nal to expla in these to you refer to Appendix 2 for some commonly used abbreviations be objectiv e and factual be specific and avoid general terms objective information is what is dire ctly seen, heard, felt, or smelled.

8 Seen for example, recording observations regarding bleeding, deformities, drainage, colour of urine, patient/ client posture and/or attitude heard for example, the patient/client s comments, moaning, breathing abnormalities, speech sound errors smelled for example, vomitus odour felt for example, hot, cold, dry or moist skin, range of movement subjectiv e information is your own pers onal bias, judgement or specula tio n about the patient subjectiv e statements should be avoided, that is , do not record your own emotional statements or moral judgements if you think it is important to in clude a subjectiv e statement made by the patient/c li ent or another person you can record this ( husband reports improved speech ). Guidelines for allied health assistants documenting in health records allied health Professions Office of Queensland - 4 - At a minim um, the foll owing in formation must be included in an entry: When Date and time of patient/client contact/activity Who Who was involved?

9 Patient/client, carer, nurse reported stable observations, discussed with physiotherapist What What did you observe and do? Observati ons/ events re levant to the session Therapy/ treatment provided How How did you carry out the task? with prompting and minimal assistance; walk belt Why Why did you perform this task? as per the treating therapist s instructions; as per su rgica l pathway Documentation standards record in chronological order, that is, in order of date and tim e. Check that you have the correct health record and ensure that the front and back of every page has an id entifying la bel/in formation attached. Black pen only. Ensure your writing is le gib le . Avoid spare lines and gaps within and between entries. Always time and date entries: try to write the entry as soon as possib le after the interventio n, if there is a lo ng dela y, record when you saw the patie nt as part of your entry document the time that you write the entry use a 24-hour clock format 9am as 0900, 1:30pm as 1330 do not time or date entries retrospectively (that is, back-date).

10 Clearly label your entrie s: use a discipline sticker, for example, Speech Pathology indicate you are an AHA sig n entrie s and clearly print name and designatio n (tit le) once you have been deemed competent by your supervisor, there is no requirement for the allied health professional to counters ig n entrie s. If errors are made: draw a neat sin gle line thro ugh writ in g. Sign and date this change. If the whole entry is an error, write Written in error or Written in wro ng chart do not use white out correction flu id (liquid paper) do not retrospectiv ely amend. Complete and then discuss the templates in Appendices 3 6 with your supervisor to determine if this is how you should document at your f acility. Guidelines for allied health assistants documenting in health records allied health Professions Office of Queensland - 5 - Alt ernative documentation formats SOAP A number of HHSs have adopted the SOAP system for cli nical documentation as follows: S = subjectiv e information O = observati on/objectiv e information A = assessment P = pla n.