Calvary Health Care Sydney
CLINICAL DOCUMENTATION
Updated May 2013
WHO Guidelines for Medical Record
& Clinical Documentation
WHO Guidelines for Medical Record
& Clinical Documentation
• Documentation and record keeping is a
fundamental part of clinical practice. It
demonstrates the clinician’s accountability
and records their professional practice.
• Documentation is the basis for
communication between health
professionals that informs of the care
provided, the treatment and care planned
and the outcome of that care as a continuous
and contemporaneous record.
WHO Guidelines for Medical Record
& Clinical Documentation
• Documentation is a record of the care and
the clinical assessment, professional
judgement and critical thinking used by a
health professional in the provision of that
care.
• Documentation must be patient focused and
based on professional observation and
assessment that does not have any basis in
unfounded conclusions or personal
judgements.
WHO Guidelines for Medical Record
& Clinical Documentation
• Documentation is often used to evaluate professional
practice as a part of quality assurance mechanisms
such as performance reviews, audits and
accreditation processes, legislated inspections and
critical incident reviews.
• Documentation systems should promote appropriate
sharing of information amongst the multidisciplinary
teams.
• Accurate and comprehensive documentation is a
valuable source of data for data coding, health
research and a valuable source of evidence and
rationale for funding and resource management.
WHO Guidelines for Medical Record
& Clinical Documentation
• Documentation should record both the
actions taken by clinical staff and the
patient’s needs and/or their response to
illness and the care they receive.
• It should be assumed that any and all
clinical documentation will be scrutinised at
some point.
WHO Guidelines for Medical Record
& Clinical Documentation
5 Mandatory Pieces of Information
•
•
•
•
Date
Time (24hr)
Name of therapist
Designation (e.g. Physiotherapist,
Physiotherapy student)
• Signature
Writing in Clinical Notes
• Patient identification sticker in the top right hand corner
– If missing you must write the patients name, MRN and DOB.
• A physiotherapy sticker is placed at the beginning of the entry
or written if unavailable.
• Name of clinician should be clearly written next to the
physiotherapy sticker and (Yr xx Student)
• The full date and 24 hour time on each entry in the left hand
column
• All entries are written using BLACK ink only.
• Writing must be legible and kept within the margins of the
page
• Each entry must be signed on the final line and countersigned
by your supervisor
Writing in Clinical Notes
• Be aware that other people may wish to view the
records at the same time as you especially with new
patient’s notes. Place all notes back in the
designated area after they have been viewed or
written in.
• You should check every one of your patient’s notes
in the morning before seeing them so you are
informed of any changes that may have taken place
overnight which affects your treatment.
• Medical records must be completed within 24hours
of seeing the patient. An entry is classified as late if
entered on the next rostered shift. Any late entry is
identified as a ‘late entry’ with the date and time of
entry noted.
Write what you see…
• Documentation must be based on professional
observation and assessment.
• Write what you see, not what you think you see.
• The person who performed, observed or heard an
event or treatment makes all entries. No entry is
made for anyone else.
• An entry should be accurate, brief and complete.
• Reference should also be made where a patient
refuses any treatment or acts contrary to advice.
• The meaning of a medical term is used in the correct
context and meaning is correct.
• Language used is uncomplicated and easy to
understand to assist all health professionals reading
the record.
Writing in Clinical Notes
 Any errors made while writing an entry in a patient’s
medical record should be dealt with by drawing a line
through the incorrect entry and initialling it before
continuing on.
 No space is to be left within or between entries, which
would enable words to be added. If there are any blank
spaces a line is drawn through them.
• Any entry that continues over the page has the date and
‘continued’ (cont’d) documented.
• The word ‘addit’ is written if additional information to a
clinical record entry is made immediately after a previous
entry by the same person. The date and time is also
written and then signed off.
• Only official abbreviations, symbols and acronyms are
used as per CHCS abbreviations policy and “The
Australian Dictionary of Clinical Abbreviations and
Symbols” published by the HIMMA.
Writing in Clinical Notes
• For every patient entry you should include:
- Subjective assessment (S/)
- Objective assessment (O/)
- Treatment provided (Rx/) and re-assessment
(//) if any changes occurred as a result of
treatment
- Treatment plan (P/)
• If you see a patient twice a day you have to
refer to the two occasions of service.
Treatment Documentation Example
Rx:
• Mobilised outdoors to bus stop and back, plus half way to bus stop and
back (~300m) a/a
// occasional prompting required to maintain step length on left.
Client sometimes unable to clear prosthetic foot so toe drags on
pavement increasing falls risk. Client still requires supervision with
outdoor mobility
• Sideways stepping along kitchen bench x10 hands close together
// step length reduces when client places hands together
• Stepping with left foot and only right hand support 4x5
// requires prompting to "stand tall and stay strong" to assist in
stabilising hip on prosthesis
• Standing balance with reaching to forward target and keeping right hip
next to bench
// has difficulty completely WBing on prosthesis but improved with
prompting
• Left in prone with towel under stump for hip flexor stretch
Aiding Clinical Handover
• Another physio should be able to read
your notes and replicate treatment.
– What was done?
– Where?
– How many times? For how long?
– How much help?
– Patient response to Rx?
THE INITIAL ASSESSMENT
The Initial Assessment
Introduce yourself and what you will be doing as a
physio/student.
History of Presenting Illness (HPI):
• The history of the current complaint. (When? How?
Lead up?)
• What has been done to date (e.g. investigations,
surgery, other treatment)
Past Medical History (PMHx):
• Other medical conditions the patient has especially
the ones that will guide or affect your treatment
approach. Try and provide dates.
The Initial Assessment cont.
Social History (SHx):
• Living arrangements, (type, stairs/rails, modifications).
• Presence of family/carer, family members; support
provided.
• Social services, social activities and access to the
community.
Pre-morbid Level of Function:
• Need to get an idea what their functional level was prior
to hospitalisation. How far could they walk? What walking
aid? Limiting factor?
• Were they housebound or could they access the
community?
• Could they walk stairs/outdoors?
• Falls history- how many?, injuries sustained?, how did
they occur? could they get up, how long did they lie
there?
The Initial Assessment cont.
Subjective Assessment (S/):
• Should only include what the patient tells you, no
assumptions or judgements.
Objective Assessment (O/):
• Bed Mobility- including moving across and up the bed and
rolling and in and out of bed.
• Sit to stand- height of chair, use of upper limbs.
• Transfers- bed to chair/chair to bed.
• Mobility:
– Assistance/aids required
– Quality of movement including step length, base of
support, hip/knee extension, gait pattern (step
to/step through/shuffling gait).
• Pain 0-10 (rest and mobilising).
• Strength and range of motion of affected joints.
The Initial Assessment cont.
Goals:
• Short term and long term goals should be set.
• Usually the long term goal will be the discharge goal
and the short term goals should be related to the
objective measures.
Objective Assessment in gym:
• More thorough assessment of strength and ROM.
• Outcome measures (e.g.)
–
–
–
–
3MWT
Tinetti
Berg
TUG
Case Conference Reporting
For the patients first Case Conference report their pre morbid
physical functioning i.e. mobility aid, community access, falls Hx,
exercise tolerance.
Patients motivation/ gym attendance/ any behavioural/pain
issues.
Bed Mobility:
 Amount of assistance required
 Height of bed
Sit to Stand:
 Amount of assistance required
 Quality of performance
 Height of chair
Case Conference Reporting
Mobility Status:
• Walking aid
• Independent/supervision/assistance
• Distance
• Limiting factors
• Quality of gait
Stairs: (particularly if the patient has stairs at
home)
• Comment on the patient’s ability to
negotiate stairs mimicking home
– e.g. number of rails, number of stairs, assistance
required
Case Conference Reporting
Outcome Measures:
• E.g. 3MWT, Tinetti, BBS, TUG
Time Frames:
• In terms of achieving short term and long term goals, home visit,
discharge
Discharge:
• Towards discharge consider if any referrals for physiotherapy are
required
• Raise any potential barriers to discharge
Other:
• Report patients at risk of falling so staff increase alertness
• Any other issues pertinent to the particular patient and their
rehabilitation including discussions with the patient and their families
Some Abbreviations
 ADL - activities of daily living
 Q/S – Quadstick
 BOS - Base of support
 RF – Rollator frame
 Bro – Brother
 SIL –sister in law
 BIL – Brother in Law
 SNAP – sub and non acute patient
classification system
 B/T – Break-through medication
 CPCT – Community Palliative Care
Team
 TUG – Timed up and go
 DIL – Daughter in Law
 2wrf –two wheeled rollator frame
 FIVD – fixed interval variable dose
 4wrf –four wheeled rollator frame
 GAS – Goal attainment scaling
 3MWT –three minute walk test
 G’mo – Grandmother
 // bars – parallel bars
 G’fa – Grandfather
 // - re-assessment
 H/care – homecare
 X –Exercise