DOCUMENTS AND RECORDS

DEFINITIONS

      Documents are formatted information that can be accessed and used by a person. They have a beginning and an end and may be represented through alphanumeric text, vector data, a digital map, spreadsheets and databases, moving images or audio data. Regardless of format, documents serve the purpose of conveying information.

      Records are document that have been set aside as evidence and protected from alteration or change. The critical factor is how “set aside” is defined. In paper “being set aside” means placing a document into a filling system from which it can be retrieved. With digital technologies, the same result is achieved by transferring an electric document from an operational environment into a record keeping system.

ELEMENTS OF RECORDS

    Content is the information in a record, the idea or concept, the facts about an event, a person, an organization or other similar act that are recorded to document the transaction itself.

      Structure refers to the physical and logical attributes of records. Physical attributes of a record include such things as the size and style of type, line spacing, page margins and the agency logo. Logical attributes consist of the logical arrangements of the record. For example, the structure of a memorandum would include a header (the name of the sender, the date, the subject of the memo and the recipient of the memo), a body (the actual content in one or more paragraphs) and the authentication (Signature).

      Context explains the “why” of the record. A single record derives its trustworthiness and usefulness from its association with other records that collectively tell the story of an event or activity.

DOCUMENTATION IN OT/PT

    A written/printed paper furnishing information or evidence or a legal official paper furnishing details of records.

Reasons:

1.      For administrative advice

2.      To maintain evidence

3.      To keep records

4.      To follow up cases

5.      To conduct research

6.      To support legally

7.      To guide course of action

8.      To maintain authentic records

9.      To write progress notes

10.  To pursue case in future

·        GLEAVE defined RECORD as a written statement to preserve memory and to present accurate evidence of facts and events.

·        Report is defined as written summary of facts or occurrence to communicate the information as “Progress Report” and “Discharge Summary”.

·        Documentation should be clear, easier, accurate, objective and complete.

·        OT/PT are responsible for keeping accurate records and writing appropriate records to document the treatment program and patients progress.

 

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