Ways of documentating evaluation icf pattern review notes, daily progression notes and discharge summary. REFFERAL NOTES WRITING. from physiotherapeutic guidlines

1. DOCUMENTATION
IN PHYSIOTHERAPY

2. OBJECTIVES
• Definition and need of documentation
• Guidelines for documentation
• Types of documentation
• Ways of record entering
• Types of clinical notes
• Informed consent
• Confidentiality
• Maintenance and destruction of documents

3. • CONCLUSION: Out of 100 records only 4.3% achieving a rate of 100 per cent completion In
total, and 81.7% were at least 50 per cent completed, which was considered a reasonable
overall standard. While the overall standard of documentation was deemed acceptable, it was
clear there was room for improvement.

4. • CONCLUSION: Findings from the study suggest that physiotherapy documentation accuracy
needs to be improved in order to promote optimal continuity of care, improve efficiency and
quality of care, and recognize patients’ needs and adverse events. Due to poor documentation,
it was not possible to establish a relationship between the accuracy of physiotherapy report
about the admission of patients and physiotherapy diagnoses, interventions, and progress and
outcome evaluations.

5. INTRODUCTION
• DEFINITION: Documentation is a material that provides official
information or evidence and that serves as a record.
• Medical records are the important tools to perform the affair of
treatment and prevention and are known as the reflecting mirror of the
medical affairs in an institute.
• Documentation is used as the foundation of the programming and
decision making management in education, research and health, are
the most valuable criteria of hospital staff professional assessment.
• Documentation of medical records is often used to protect the
researches, train medical care staff, general studies and qualitative
studies.

6. General guidelines for documentation:
Documentation is required for every visit/encounter.
All handwritten entries shall be made in ink and will include original
signatures. Electronic entries are made with appropriate security and
confidentiality provisions.
Errors should be corrected by drawing a single line through the error ,
signing and dating the entry or through the appropriate mechanism for
electronic documentation that clearly indicates that a change was made
without deletion of the original record.

7. All documentation must include the patient's/client's full name and
identification number. All entries must be dated and authenticated with
the therapist's full name and appropriate designation.
Documentation should include indication of no shows and
cancellations.
Documentation by graduates or physical therapy assistants shall be
authenticated by a licensed physical therapist.
Documentation should include the referral mechanism by which
physical therapy services are initiated.
Ex: Self-referral/direct access
Request for consultation from another practitioner

8. Areas of
documentation in
physiotherapy
Home visits
. Financial records
. Patient evaluation
and progress records
Referral records
Clinics
. Financial records
. Patient evaluation
and progress records
Referral records
Hospitals
Patient
-OPD
-IPD
Departmental records
Staff Record
Equipment records
Hospital cum
college setups
Patient
-OPD
-IPD
Staff Record
Equipment records
Student records

9. WAYS OF DOCUMENTATION:
MANUAL ENTERING:
It is a paper and pen method of entering the data , stored by filing in folders.Legally
they are more acceptable as a documentary evidence ,as these are difficult to tamper
with.
Disadvantage-
The need for large storage areas and difficulties in the retrieval of records
ELECTRONIC HEALTH RECORDING:
• The medical records are computerized. These are neat and tidy, and can be easily
stored and retrieved. These require a mandatory password protection and backup
system. Access to these safety software is only given to authorized personnels.

10. Types of documentation
1. Demographic records
2. Clinical notes records
3. Departmental records
4. Financial records

11. DEMOGRAPHIC RECORDS
Demographic data is a objective characteristics of a population such as:
-Age, Gender, marital status, family size, present or prior disease, blood
group, Income, education & residency.
USES:
This information helps the care team communicate effectively with
patients, as well as understand a patient’s culture, which may affect their
health. By knowing more about the patients that we can serve better.

12. • Clinical Health records are accurate, complete, authenticated and
legible information gathered in a timely manner by health care
professionals regarding the mental or physical state of a client.
• Record writing pertains to a systematic way of putting together
information regarding the client.
CLINICAL HEALTH RECORDS:

13. Uses of clinical records writing:
1. Provides a standardized way of communication in the multidisciplinary
team.
2. In a multidisciplinary team, clinical record is a way for continuation and
coordination in patient care.
3. Aids informed decision making for patient management.
4. Aids targeting of diagnostic tests and treatment plans without unnecessary
repetition.
5. Early diagnosis = more time spent in treatment.
6. Help in analyzing the treatment results.
7. Help in the scientific evaluation of patient profile.
8. Provides information in legal cases and for claiming insurance.
9. Improves time management.

14. Types of clinical notes
• Evaluation notes
• Daily notes
• Review notes
• Discharges notes

15. Record writing for Evaluations
Subjective Chief complaint in terms of functional limitation
History
Pain history
Ex-
I cannot properly left lift my leg on my own
 I lose balance while walking.
HOPI: Patient had stroke 3 weeks ago, he had a loss of sensation
and weakness on R side of his body.
Past medical: HTN, diabetes mellitus since 3 years and was
poorly controlled
Personal history: Chronic Smoker, alcoholic.
S.O.A.P Format

16. Objective Systems Review
Tests
Measurements
Outcome measures- Disease specific
Ex-
Voluntary Control lower limb – poor
Spasticity of gastrosoleus – 2
BBS-24
Feugal Meyer score- 94 (moderate affection)
Sensations- deep sensations diminished
Observational gait analysis- circumductory gait
Spatiotemporal gait assessment- reduced gait speed and
shorter left side step length.

17. Assessment
(Analyse)
Reason and correlate the subjective, objective findings, activity
and participation limitations.
Diagnosis by the physical therapist shall include impairment,
activity limitation, and participation restrictions.
Ex-
The 40 yr old male is a subacute c/o hemiparesis who came with
c/c of losing balance while walking.
The spasticity, reduced voluntary control and diminished deep
sensations have lead to decreased static and dynamic balance.
The reduced standing balance have lead to gait deviations.
There is inadequate sequential activation of muscle groups of the
left lower extremity.

18. ICF FORMAT

19. Plan of care Short term and long term goals to set.
Goals shall be stated in measurable terms that indicate the predicted
level of improvement in functioning, proposed duration and frequency
of service required to reach the goals.(SMART)
Anticipated discharge plans.
A general statement of interventions to be used.
Ex- Short term goal: thrice in a week for 3 months
Patient should walk without fall of fear for 500m on even ground
Patient should be able to walk with an assistive device for 200m on uneven
ground.
-spasticity management
-Balance training
-Strengthening
-Gait training
Long term goal: twice in a week for 3 months
Patient should walk without assistive device for 1km on uneven surface.
Patient should be able to use transport independently.
-Endurance training
-Balance training

20. Record writing for subsequent Visits:
 It is important in the patients who daily improvement is expected.
Ex- musculoskeletal conditions.
Patient self-report (as appropriate).
Record of specific interventions provided, according to the FITT criteria of
exercise prescription. (frequency, intensity, type of exercise and time/duration)
Ex: ten repetitions , three sets, 1kg weight, concentric Knee extension.
Equipments provided.
Ex- cane, AFOs

21. Changes in patient impairment, activity limitation, and participation restriction
status as they relate to the plan of care.
Response to interventions, including adverse reactions, if any.
Referral notes.
Documentation of plan for the next visit, that may include:
The interventions to be added with objectives
Progression parameters
 Precautions, if indicated

22. Record writing for Patients on review
 Documentation of selected components of examination to update patient's
functioning or disability status.
Patient adherence to patient-related instructions.
 Interpretation of findings and, when indicated, revision of goals.
When indicated, revision of plan of care, in correlation with documented goals.

24. Discharge Record writing:
• Current physical/functional status.
• Degree of goals achieved and reasons for goals not being achieved.
• Discharge plan related to the patient continuing care.
• Home program.
• Referrals for additional services.
• Recommendations for follow-up physical therapy care.
• Family and caregiver training.
• Equipment provided.
• Caution notes- in situtations to consult a healthcare professionals.

25. INFORMED CONSENT
• Informed consent is a decision to participate in assessment, treatment or research,
taken by a competent individual who has received and understood the necessary
information. If the patient is younger than 18, a parent/guardian will need to give
consent.
• Competent individuals should be provided with adequate, intelligible information
about the proposed physical therapy. This information should include a clear
explanation of:
• the planned assessment
• the evaluation, diagnosis, and prognosis/plan
• the treatment to be provided
• the risks which may be associated with the intervention

26. • the expected benefits of the intervention
• the anticipated time frames
• the anticipated costs
• any reasonable alternatives to the recommended intervention
• If a medical practitioner attempts to treat a person without valid consent, then
the patient may sue the medical practitioner in case of negligence.
• He will be liable under both civil and criminal law. The consequences would be
payment of compensation (in civil) and imprisonment (in criminal).
• In certain extreme cases, there is a theoretical possibility of criminal prosecution
for assault or physical contact with another person without that person's consent.

27. CONFIDENTIALITY OF RECORDS:

28. • Confidentiality is the principle of maintaining the security of
information elicited from an individual in the privileged circumstances
of a professional relationship.
• It covers:
• Patient physical and mental health
• Any clinical information related to individual’s diagnosis and
treatment
• Photographs, video and audio tapes.

29. Privacy violations in the healthcare sector include :
• Disclosure of personal health information to third parties without
consent/inadequate notification to the patient.
• Unnecessary collection of personal health data
• Provision of personal health data to public health, research, and
commercial uses without de-identification etc..

30. Where disclosure of personal health information is
permitted
• During referral
• When demanded by the court or by the police on a written requisition
• When demanded by insurance companies as provided by the Insurance
Act
• When required for specific provisions of workmen's compensation
cases, consumer protection cases, or for income tax authorities
• Communicable disease investigations and registration

31. Types of documentation
1. Demographic records
2. Clinical notes records
3. Departmental records
4. Financial records

32. •These are the statistical records regarding the number of patients
,status of equipments and the revenue generated. The statistics are
calculated bimonthly or monthly and yearly.
• Daily attendance of the patients reporting to the department should
be made, categorisation shall be done according to the purposes of the
visit.
•No. Of evaluations
•Patients on follow-ups.
•Number of discharges.
•No. of treatment sessions
•Attendance of the staff .
Departmental records

33. • Number and status of equipments - Equipment maintenance register
is to be maintained. Warranty notes should be filed with the date of
purchase and cost of the item. Servicing timings should be charted .
• Maintenance of charts to aid servicing of safety equipments .
• Ex- fire extinguisher, first aid, defibrillator kit etc.
• Maintainace of cleanliness record regarding the frequency of
departmental pest control and disinfection.

34. Uses of Departmental record writing
1. The departments needing more attention and resources can be
identified and hence the resources namely, equipments, space and
manpower can be redistributed.
2. Helps the owner in planning infrastructural and manpower
strategies for future medical care.
3. Helps in auditing the quality of healthcare services.
4. The progress of each department can be monitored and appropriate
actions can be taken.

35. FINANCIAL RECORDS
• Financial statements are used to give you much more than just a
snapshot of your business health.

36. FILING & ARRANGING OF RECORD
• Introduction
Medical records in most health care institutions are filed numerically according to patients
medical record numbers. In the past, some hospitals have filed records according to patients
names, discharge numbers, or diagnostic code numbers. Alphabetic filing by patient names is
more cumbersome and subject to more error than numerical filing. Filing by discharge
numbers and diagnostic code numbers is generally unsatisfactory because other important
records or registers in the facility are concerned exclusively with medical record numbers
1. Numbering System
Three types of numbering systems are currently in use in health care facilities.
They are:
Serial Numbering System.
Unit Numbering System.
Serial Unit Numbering System.

37. 1. Serial numbering:
In serial numbering the patient receives a new number each time he is
registered or treated by the hospital. If he is registered five times, he
acquires five different medical record numbers.

38. 2. Unit numbering:
• Unlike the serial numbering systems, the unit numbering system provides a
single record, which is composite of all data gathered on a given patient,
whether as an outpatient, inpatient or emergency patient.
• The patient is assigned a medical record on his first visit, which is used for all
subsequent visits and treatments.
• His entire medical record is thus in one folder under one medical record
number.

39. 3. Serial unit numbering:
This numbering system is a combination of the serial and unit numbering
systems. Although each time the patient is registered he receives a new medical
record number, his previous records are continually brought forward and filed
under the latest issued number.
 Annual numbering:
Serial numbering that includes the last two digits of the current calendar year,
may be used by hospitals that primarily serve a transient population. In this
system, the two digits for the year are added to the end of a serial number.

40.  Family numbering:
• Another adaptation of unit numbering is the family numbering system. Family
numbering usually consists of placing extra pairs of digits, which signify
placement of the individual in the household.
• These digits are usually placed immediately before the regularly assigned
number.
• Prefix number pairs have a definite sequence and meaning. All patient
information on one family is thus filed together by the family number.

41. Missing records
• Despite the extensive measures adopted to have good control of records, a
certain percentage of records are not found where they are supposed to be.
• This could be due to not receiving the file, not filing in appropriate place, or
misfiling.
• Under these circumstances, when a doctor insists on obtaining the original
record for rendering care, the medical records technician must create a duplicate
record with a similar number and with all previous ID data.
• The medical record technician should retain the duplicate record and
immediately trace out the original records and incorporate the forms of the
duplicate record into the original record. The record should then be filed.

42.  Patient having multiple records
• As a general rule, each patient should have one record and one number. Due to
improper system or negligence of the hospital staff, the patients may have more
than one record.
• In that situation, it becomes necessary to retain one record by canceling the
others. The appropriate procedure is to retain the new record. The remaining
records have to be cancelled and given cross-reference numbers.
• All the documents in the cancelled records need to be moved into the retained
record.
• The cancelled empty folders with the cross-reference numbers should be
placed in their respective area. Any cancelled record number should never be
allocated to a new patient.

43. HOW LONG TO KEEP THE RECORDS?
 Maintain health records in a standard proforma for 3 years from
commencement of treatment, according to Indian Medical Council
(Professional conduct, Etiquette and Ethics) Regulations, 2002.
21 year for neonatal patient (3yr + 18 year).
For children 18 year of age + 3 year.
For mentally retarded patient forever till hospital/institution is
working.

44. Guidelines for destruction of health records
• Public notice of destroying the records in English news paper and in
one vernacular paper mentioning the specific date up to which
destruction will be sought.
• Give a time limit of 1 month for taking away records for those who
want the records with written consent.
• After 1 month destroy the records up to date specified.

45. Take Home Message
Thus there are 3 fundamental principles of documentation to be always kept in
mind by medical practitioners –
 Record the risk-benefit analysis of important decisions in the clinical care of
the patient.
 Make use of clinical judgment at critical decision points.
The last principle of documentation relates to the patient’s capacity to
participate in his or her own care.
(Ref- Thomas G. Gutheil, Fundamentals of Medical Record Documentation, 2004 Nov; 1(3): 26–28.)

46. REFERENCE
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6. Physiopedia
7. APTA guidles for maintaing good clinical records.
8. http://clinicalestablishments.gov.in/WriteReadData/597.pdf
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10. https://www.wcpt.org/sites/wcpt.org/files/files/PS_Informed_consent_Sept2011.pdf
11. https://www.semanticscholar.org/paper/Medical-Record-Documentation%3A-The-Quality-of-
Phillips-Stiller/4e7ac89bfe20346a1a8d929923d790ac1a3b9037
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47. THANKYOU
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