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Record Keeping

Felicity Burke

Speech Pathology Practice Leader

Clinical Innovation and Governance, FACS.

Acknowledgements of contributors to slides: Tess Southcombe, Susan Heiler, Margaret Balin, Rochelle Meurant, Lorren

Krilich & TsenAie Levsen

Complex Case Management and Behaviour Support Conference Armidale September, FACS 2016

• Who is here today?• What organisation are you from?• Why are you here?

Let’s keep a record!

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Purpose of record keeping • Legal, ethical and professional

responsibility• Ensure that current and accurate records

of the services provided are kept

Why the fuss?

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• Client safety• Chronologically recording the sequence of

events• Evidence of service delivery • Evidence of decision making (process)• Evidence of care taken* including-• Consent documentation and procedures

Why is it important?

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• Freedom of Information Act 1982 (FOI Act). The FOI Act is the legislative basis for open government in Australia and covers Australian Government ministers and most agencies.

• State Records Act 1998 New South Wales Government

• The policies and procedures where you work

Legislation

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• ?• ?• ?• Discipline specific Codes of Ethics for

Professional Associations• Position Statements/Procedures on

Record Keeping for specific disciplines

Relevant policies and procedures in your org ?

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• Clinical Reviews- Critical Incidents Review Panel and NSW State Ombudsman’s Office

• Recommendations led to release and training internally in FACS specifically for clinicians. Approved document released Dec 2015

My background in this area..

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• What issues arise in record keeping?• What potential problems are there?• What audits/quality standards exist?• Is your org or your staff at risk?• Think back to our beginning exercise-

what was lacking?

Think of your organisation, your reviews

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• Staff understand their legal requirements in regards to record keeping

• Staff have a clear knowledge of the structure and what is included in progress^ notes

• Staff have a clear knowledge of reports and documents required including stages and time frames

• Staff apply & document clinical/professional reasoning for services supplied

• Content & accessible language are used

What is good record keeping?

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– Records what happened/ what needs to happen– Documents goals, interventions, plans, outcomes– Enables evidence base record for service provision– Provides evidence of increasing/ compounding

issues or action areas, changes, increased funding– Highly important in handovers, working with other

agencies and team members*– Allows ALL team members to be up to date– When staff leave there are clear notes and reports

for continuity of care

Importance for the service to the person

10Saturday, October 1, 2016

Clinical Record Keeping Fact Sheet

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Internal FACS document for clinicians in our organisation which covers:• Purpose• Progress notes• Progress note structure• Document writing• Policies • Discipline specific

documents• References

• Be recorded on system (within 24 hours)*• Be factual, objective and accurate• Non-judgmental and respectful• Give a chronological history of all actions• Document consent, including any attempts

and variations used• Not use jargon or abbreviations (unless an

explanation is provided)

Progress^ notes should


• Contain the date, details and people involved, duration of contact

• Add people’s job titles and contact information• Document assessment/interview details &

findings• Document intervention/actions, goals, proposed

intervention and any risks or alternatives that were discussed plus clinical or professional reasoning

Content of progress^ notes


• Detail training or information provided• Outline any risks or concerns• Document if intervention was unable to be

completed and reasons why• Contain a plan for the next session/meeting• Include correspondence with others • Provide the system references for

documents

Content of progress^ notes cont.


Thoughts about simplification of systems

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• We need to simplify the red tape and streamline systems so people can do their jobs

• At the same time we need people to keep good records and be safe and within the operational guidelines of the organisation

• It can be a balancing act

• Descriptive / Narrative • SOAP

– S: subjective– O: objective– A: assessment / interpretation– P: plan

Progress^ note structure


Subjective versus

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• Watch a You Tube video from PortlansState University about what is Objective and Subjective Length: 2:31

• Objectivehttps://www.youtube.com/watch?v=Iv1725yFrBw

• It was observed……• The person reported…….• Mother stated…….• Practitioner/manager/staff member

informed…….• Person advised……

Objective information


• It appears……• Practitioner/manager/staff member

assumes……• It is possible …….• It is unclear whether …….

Subjective information


• Where are these recorded in your org ?*

• What should be recorded ? **

• How do you sign these?

Progress^ notes quick quiz

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Documents should :• have a clear purpose• be dated and signed • be able to be understood by the person

with disability & or their family/carers/staff• not contain abbreviations or jargon• be stored on systems (include ref number

and be cross referenced in notes)

Document writing

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Accessible Information

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• Information should be tailored to the audience

• Training and help for staff with making information accessible in many different formats is available

• Look for Plain English training and see the Accessible Information Checklist link on end slides

1. Is this an example of a good or bad progressnote?

2. What could be changed or added in eachexample?

QUICK QUIZ if there is time…


Example 1Attended H/V with mother, father and Julie. Julie was sadall visit. Mother and father were giving her too manyinstructions and sometimes yelling at her. Provided 3 partvisual schedule with PCS, discussed implementation andreview in 2 weeks.

Jo (Speech Pathologist)

CASE EXAMPLE Speech pathology


Attended home visit with Julie on 2/3/2016 to discuss use of visual schedulewith her and her parents and introduce part 3 of this schedule as outlined in theplan (TRIM AH16/3260). Visit was for one hour.Mother and Father were present and tended to give Julie multiple instructions,sometimes with raised voices. Julie appeared sad during this visit but wasusing her previous visual schedule (see TRIMXXX) with 5 of 6 accuracy on 6occasions.Provided 3 part visual schedule with Picture Communication Symbols (PCS)for: afternoon tea, reading, music, park, car, Nonna, dancing and dinner withattached finished box. Discussed using the schedule with Julie, preparing herfor what will happen in afternoons and to help her anticipate what she will do.Discussed with parents use of simple language “first ___ then ____ then ____”and “_____ finished, now _____” while pointing to the PCS or helping Julie putit in the finished box. See full details TRIM AH16/3261Plan: Parents to trial using the visual schedule every afternoon after school andto review in 2 weeks. Parents to record data re schedule on form provided &call for any support.Jo Rogers (Speech Pathologist Grade 3, Benkstoon CST)

Is this better?

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What do you need consent for?

Do you record duration of contact?

How much detail is needed for clinical reasoning?

What details do documents in official systems need?

Progress notes should be F******, O******** and A*******.

Quick quiz

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• Accessible Information Checklist• A Tool for Clinical Reasoning and

Reflection Using the International Classification of Functioning, Disability and Health (ICF) Framework and Patient Management Model

• Capacity Toolkit

Additional resources

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More resources

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• Fact Sheet Person Responsible• Freedom of Information Act 1982 (FOI Act)

• Helen Sanderson & Associates Tools for Person Centred Risk Planning

• State Records Act 1998 New South Wales Government