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

2. 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

3. 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

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

5. 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

6. 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?

7. 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

8. Documentation Requirements
Be dated and timed (including retrospective time)

9. Documentation Requirements
Document initial entry and acknowledgement of referral

10. Documentation Requirements
Document consent – use existing consent form if available

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

12. 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.

13. 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”

14. 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)

15. 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

16. 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.

17. 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

18. 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.

19. 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)

20. 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

21. 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?

22. 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

23. Example: Psychology Proforma

24. Example: Mental Health Pro-forma

25. 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

26. Questions??