week 9 Flashcards
(10 cards)
What are the key purposes of clinical documentation?
Provides a legal record
Communicates with other health professionals
Supports clinical reasoning and accountability
Informs planned treatments and outcomes
Aids continuity of care
What are the mandatory elements for every entry in clinical notes (NSW Health)?
Patient details (e.g., sticker)
Date & time (24-hr)
Signature
Name
Designation (e.g., student physiotherapist)
What must be included on every page of a clinical record?
Unique identifier (e.g., MRN)
Patient’s full name
Date of birth
Sex
Who owns the physical patient record?
The practice or hospital. However, the patient has rights to access, correct, and transfer records.
How long must patient records be retained?
Minimum of 7 years
Until age 25 if patient was under 18 at time of treatment
What is required if a private health insurer requests access to records?
Obtain patient consent
Patient can deny access
What should you do if you receive a subpoena for clinical records?
Comply with the request and seek legal advice if unsure.
What are some common documentation mistakes?
Not dating or signing entries
Illegible notes
Use of unapproved abbreviations
Not documenting cancellations, phone calls, or group therapy
How should errors in documentation be corrected?
Cross out with a single line
Write “written in error” with initials
Do not use white-out or overwrite
What is the structure of a SOAP note?
Subjective: Patient’s report
Objective: Measurable/observable data
Assessment: Clinical interpretation & goals
Plan: Future treatment steps
