Documentation in Occupational Therapy and Physiotherapy

INTRODUCTION

Document is an extremely effective tool for advocacy. It is often key to success when dealing with difficult situation. It calls for accountability and also allows for kudos when things go right.

It is your job to utilize tools that will enable you take carefully prepared documentation. You have written to the case presentation and read it aloud. This document be included as part of your parent input into the written records. Your document is written input, which should hold equal weight with other information presented & considered at case Conference/ Meeting/ Seminar/ Workshop or with other professionals of the case in respect of any patient.

            It is being stressed for many years in health system, that proper documentation is very much needed by professionals of OT/PT giving a legal status to the patient care under their supervision. The same is stressed in CPA also.

            Document what you & patient says, because it keeps the record clear without any misunderstanding. Verbal case handling must be documented after writing it in patient’s case file with signatures & date.

IMPORTANCE OF DOCUMENTATION

1. Backbone of records in healthcare system.
2. Maintain records of patient if incorrect then it is malpractice, negligence.
3. Legal security if properly maintains.
4. Effective tools to preserve records.
5. Key to success for difficult situations.
6. Makes individual accountable.
7. Merit to keep proper records.
8. Input to account work & effort.
9. Credited towards excellent record keeping it meticulously done.
10. Maintain case clarity on treatment.
11. Maintain white actions.
12. Dated writing helps in legal cases.
13. Record of treatments/ Test/ Advised by treating therapist.
14. Properly documented records of patients settle legal cases fast.
15. Well-documented records establish therapist’s credibility.
16. Proof of patient care.
17. Major treatment records.
18. Helps to record aspects of patient’s life: History and Charting

THE MEDICALLY ACCEPTED GUIDELINES

 ·        Be factual, consistent and accurate.

·        Be written as soon as possible after an event has occurred, providing current information on the care and condition of the Patient/Client.

·        Not include Abbreviations, Jargon, meaningless phrases, irrelevant speculation and offensive/ subjective statements.

·        Be accurately dated, timed and signed.

·        Be readable on photocopies (i.e. black ink)

·        Be written wherever possible, with the involvement of patient/client.

·        Be written in terms that the patient/client can understand.

·        Be consecutive.

·        Identify problems that have arisen and action taken to rectify them.  

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