Documentation “If it’s not documented, it didn’t happen.” Psychology Directorate The Psychology Directorate acknowledges Allied Health in the development of this presentation.

Session objectives On completion of this session you will be able to: Describe what constitutes the medical record Outline the expectations for documentation at Monash Health List the key requirements for documentation completeness Explain where to find organisational documentation policy and procedure information

Medical Records “The Health Record is a medico-legally sound collection of information whether in paper or electronic format, which health care providers contributing to the care of the patient/client, record all details of the communication, decision making and action taken of the care, or contact/service provision” Provides an accurate reflection of the services provided in the patient’s episode of care. Tool to communicate to the: Health care team & enables the Verification of care provided & Assists with: Accreditation Peer review State audits The SH medico-legal framework is in place to assist with decision making and the provision of medical care to our patients including issues arising from professional liability & informed consent. Therefore - protecting the legal interests of the patient/consumer/client and health care professionals

Expectation All staff and students are expected to document in the health record in a fashion that meets at least minimum standards required.

Parts of the Medical Record Unit Record (UR) Number Patient Identification Data Reason for admission – admitting diagnosis Signed consent Medical History of patient/consumer/client Physical examination report Observations Progress notes which document care/treatment given and changes to conditions as it occurs Diagnostic & therapeutic orders Reports & Actions “Alert” notation for conditions such as drug reaction & others Discharge summary DRG coding data

Requirements All entries must use approved patient identifiers: These are called printed Bradma sticker OR Written Patients Surname and Forename Date of birth Gender Address Unit Record (UR) number (if available) So what are the requirements of Southern Health staff for documentation?

Requirements in General Wards (not mental health) Have a large discipline specific sticker if PSYCHOLOGY Or ensure that a clearly delineated discipline heading is used. PHYSIOTHERAPY SPEECH PATHOLOGY

Documentation Requirements Be dated and timed (including retrospective time)

Documentation Requirements Document initial entry and acknowledgement of referral

Documentation Requirements Document consent – use existing consent form if available

Documentation Requirements Be legible Entries into the health record must be clear, detailed and legible.

Requirements: Errors AVOID the temptation to scribble out errors beyond legibility! For incorrect words or sentences – simply draw a single line through, reason for the correction e.g. written in error, date and initial. For entries documented in the wrong patient’s history – draw a cross (X) on the entry, acknowledge the error and sign. No ‘whiteout’ is to be used in the patient’s /client’s health record.

Requirements All patient data is to be kept strictly confidential and secure in all work areas Do not make unnecessary or disparaging remarks regarding patients or colleagues REMEMBER: “patients have the ability to access their medical record through the Freedom of Information Act”

Requirements All entries must: Be written in BLACK pen Be signed with printed initials, surname and designation Have contact details Use only standard abbreviations & symbols (list available on the intranet) PROMPT: Abbreviations and Acronyms Clinical Coding Symbols (75 page document)

Progress Notes Daily updates entered into the medical record documenting clinical changes, new information, results of tests May be in SOAP, narrative, or other formats Generally entered by all members of the health care team (doctors, psychologists, nurses, physical therapists, dietitians, pharmacists Kept in chronological order

Documentation Requirements Psychology students to use the SOAP Format S (subjective): This is the client’s report of how he or she has been doing since the last visit, or at initial presentation. It includes the current visit. Should include some statement/words of the patient and/or family in the account O (objective): The objective component is straightforward includes an MSE, observations of the patient/client. A (Assessment): This is where the psychologist pulls together the subjective information gathered during the interview with the client and the objective findings of the assessment or intervention. This is the assessment of the situation, the session and the client, regardless of how obvious it may be from the subjective and/or objective statements. P (Plan for future clinical work): Should reflect interventions specified in treatment plan including any homework activities or follow up between sessions. It should reflect follow-up needed or completed.

Example of SOAP Note 01/01/2001 9:35am S: “I wanted to talk to my kids about how guilty I feel about my drinking.” O: Tearful at times, gazed down and fidgeted with shirt buttons. (Can include MSE) A: Consumer has gained awareness in how drinking behaviour has embarrassed and hurt his teenage children. He expresses intense feelings related to his drinking and appears to assume responsibility for his past behaviours. P. Completed Tx Plan Goal #1. Continue with Goal#1, Obj 2, in next session. Signed and Printed Name Can also use D.A.P. Notes D – Describe A – Assess P - Plan See below for further information http://www.unm.edu/~clinic/Procedures/Forms/soap%20notes.pdf

Format Documentation format for most entries must be in your discipline specific approved format: Example: Psychology – SOAP or DAP advised Physiotherapy: SOAP Dietetics: ABCDE; ADIME Speech Pathology: SOAP Avoid leaving blank lines or spaces. Documentation format for most entries must be in a discipline specific approved format. For second or very brief entries, a more simplified format is acceptable. Avoid leaving blank lines or spaces – legal issue – leaving space allows someone else to adjust your documentation.

Range of Formats ADIME (assessment, diagnosis, intervention, monitoring and evaluation) DAP (diagnosis, assessment, plan) DAR (data, action, response) PIE (problem, intervention, evaluation) PES (problem, etiology, symptoms) IER (intervention, evaluation, revision) HOAP (history, observation, assessment, plan) SAP (screen, assess, plan) SOAP (subjective, objective, assessment, plan) SOAPIER (subjective, objective, analysis/assessment, plan, intervention, evaluation, revisions)

Multiple Interventions An entry must be made in the medical record for each patient’s interaction. Separate entries required for patients treated > once (simplified ok). For example – 1 patient seen multiple times in one day

When you don’t see a patient... In the event that you have been referred to assess a patient and you do not see the patient for any reason - Examples: patient not in room patient refuses assessment pt currently too unwell ‘What would you do?’ In the event that you have been referred to assess a patient and you do not see the patient for any reason - Examples: patient not in room patient refuses assessment pt currently too unwell ‘What would you do?’ Imperative that you still document – WHY??? Medico legal responsibilities – if there is an adverse event e.g. fall – who is responsible?

Proformas Only Monash Health pro-formas approved by medical records are to be filed. Extensive procedures on Prompt for Mental Health program documentation Must be accompanied by an entry in the progress notes documenting the completion of the form, including a brief explanation of what is on the form and the date on which the form was completed, and an indication on where it is filed. Show examples of proformas

Example: Psychology Proforma

Example: Mental Health Pro-forma

PROMPT: Policy & Procedures HIS Document process in the Medical Records (Health Records) HIS - Creation and Documentation of a Health Record Abbreviations and Acronyms Clinical Coding Symbols Assessment, Care Planning and Discharge Mental Health Documentation To access prompt documents: click on the PROMPT icon located on SH intranet home page – bottom left, 2nd from the top

Questions??