Record Keeping. Felicity Burke Speech Pathology Practice Leader Clinical Innovation and Governance, FACS.

Transcription

1 Record Keeping Felicity Burke Speech Pathology Practice Leader Clinical Innovation and Governance, FACS. Acknowledgements of contributors to slides: Tess Southcombe, Susan Heiler, Margaret Balin, Rochelle Meurant, Lorren Krilich & Tsen Aie Levsen Complex Case Management and Behaviour Support Conference Armidale September, FACS 2016

2 Let s keep a record! Who is here today? What organisation are you from? Why are you here? 2

3 Why the fuss? Purpose of record keeping Legal, ethical and professional responsibility Ensure that current and accurate records of the services provided are kept 3

4 Why is it important? Client safety Chronologically recording the sequence of events Evidence of service delivery Evidence of decision making (process) Evidence of care taken* including- Consent documentation and procedures 4

5 Legislation Freedom of Information Act 1982 (FOI Act). The FOI Act is the legislative basis for open government in Australia and covers Australian Government ministers and most agencies. State Records Act 1998 New South Wales Government The policies and procedures where you work 5

6 Relevant policies and procedures in your org???? Discipline specific Codes of Ethics for Professional Associations Position Statements/Procedures on Record Keeping for specific disciplines 6

7 My background in this area.. Clinical Reviews- Critical Incidents Review Panel and NSW State Ombudsman s Office Recommendations led to release and training internally in FACS specifically for clinicians. Approved document released Dec

8 Think of your organisation, your reviews What issues arise in record keeping? What potential problems are there? What audits/quality standards exist? Is your org or your staff at risk? Think back to our beginning exercisewhat was lacking? 8

9 What is good record keeping? Staff understand their legal requirements in regards to record keeping Staff have a clear knowledge of the structure and what is included in progress^ notes Staff have a clear knowledge of reports and documents required including stages and time frames Staff apply & document clinical/professional reasoning for services supplied Content & accessible language are used 9

10 Importance for the service to the person Records what happened/ what needs to happen Documents goals, interventions, plans, outcomes Enables evidence base record for service provision Provides evidence of increasing/ compounding issues or action areas, changes, increased funding Highly important in handovers, working with other agencies and team members* Allows ALL team members to be up to date When staff leave there are clear notes and reports for continuity of care Saturday, October 1,

11 Clinical Record Keeping Fact Sheet Internal FACS document for clinicians in our organisation which covers: Purpose Progress notes Progress note structure Document writing Policies Discipline specific documents References 11

12 Progress^ notes should Be recorded on system (within 24 hours)* Be factual, objective and accurate Non-judgmental and respectful Give a chronological history of all actions Document consent, including any attempts and variations used Not use jargon or abbreviations (unless an explanation is provided) Saturday, October 1,

13 Content of progress^ notes Contain the date, details and people involved, duration of contact Add people s job titles and contact information Document assessment/interview details & findings Document intervention/actions, goals, proposed intervention and any risks or alternatives that were discussed plus clinical or professional reasoning Saturday, October 1,

14 Content of progress^ notes cont. Detail training or information provided Outline any risks or concerns Document if intervention was unable to be completed and reasons why Contain a plan for the next session/meeting Include correspondence with others Provide the system references for documents Saturday, October 1,

15 Thoughts about simplification of systems We need to simplify the red tape and streamline systems so people can do their jobs At the same time we need people to keep good records and be safe and within the operational guidelines of the organisation It can be a balancing act 15

16 Progress^ note structure Descriptive / Narrative SOAP S: subjective O: objective A: assessment / interpretation P: plan Saturday, October 1,

17 Subjective versus Watch a You Tube video from Portlans State University about what is Objective and Subjective Length: 2:31 Objectivehttps:// v=iv1725yfrbw 17

18 Objective information It was observed The person reported. Mother stated. Practitioner/manager/staff member informed. Person advised Saturday, October 1,

19 Subjective information It appears Practitioner/manager/staff member assumes It is possible. It is unclear whether. Saturday, October 1,

20 Progress^ notes quick quiz Where are these recorded in your org?* What should be recorded? ** How do you sign these? 20

21 Document writing Documents should : have a clear purpose be dated and signed be able to be understood by the person with disability & or their family/carers/staff not contain abbreviations or jargon be stored on systems (include ref number and be cross referenced in notes) 21

22 Accessible Information Information should be tailored to the audience Training and help for staff with making information accessible in many different formats is available Look for Plain English training and see the Accessible Information Checklist link on end slides 22

23 QUICK QUIZ if there is time 1. Is this an example of a good or bad progress note? 2. What could be changed or added in each example? Saturday, October 1,

24 CASE EXAMPLE Speech pathology Example 1 Attended H/V with mother, father and Julie. Julie was sad all visit. Mother and father were giving her too many instructions and sometimes yelling at her. Provided 3 part visual schedule with PCS, discussed implementation and review in 2 weeks. Jo (Speech Pathologist) Saturday, October 1,

25 Is this better? Attended home visit with Julie on 2/3/2016 to discuss use of visual schedule with her and her parents and introduce part 3 of this schedule as outlined in the plan (TRIM AH16/3260). Visit was for one hour. Mother and Father were present and tended to give Julie multiple instructions, sometimes with raised voices. Julie appeared sad during this visit but was using her previous visual schedule (see TRIMXXX) with 5 of 6 accuracy on 6 occasions. Provided 3 part visual schedule with Picture Communication Symbols (PCS) for: afternoon tea, reading, music, park, car, Nonna, dancing and dinner with attached finished box. Discussed using the schedule with Julie, preparing her for what will happen in afternoons and to help her anticipate what she will do. Discussed with parents use of simple language first then then and finished, now while pointing to the PCS or helping Julie put it in the finished box. See full details TRIM AH16/3261 Plan: Parents to trial using the visual schedule every afternoon after school and to review in 2 weeks. Parents to record data re schedule on form provided & call for any support. Jo Rogers (Speech Pathologist Grade 3, Benkstoon CST) 25

26 Quick quiz What do you need consent for? Do you record duration of contact? How much detail is needed for clinical reasoning? What details do documents in official systems need? Progress notes should be F******, O******** and A*******. 26

27 Additional resources Accessible Information Checklist A Tool for Clinical Reasoning and Reflection Using the International Classification of Functioning, Disability and Health (ICF) Framework and Patient Management Model Capacity Toolkit 27

28 More resources Fact Sheet Person Responsible Freedom of Information Act 1982 (FOI Act) Helen Sanderson & Associates Tools for Person Centred Risk Planning State Records Act 1998 New South Wales Government 28