Patient Records

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POMR & SOAP

What is a patient record?

Anything on any media which has been gathered as a result of the work of the employee ( the physiotherapist) HSC 1999/053 For the record:

Managing notes in NHS trusts and Health Authorities www.doh.gov.uk/nhsexec/manrec.htm

Background

Developed by Dr Lawrence Weed as part of Problem Orientated Medical Records (POMR) Based upon a collection of data Formulation of problems to develop a suitable treatment programme Progress is charted and treatment plans updated to achieve specific goals

AIMS

To enhance communication and organised method Promote logical, systematicbetween team membersof recording improve problem identification To facilitate standardisation of records To utilise a problem-solving process when formulating treatment To facilitate quality control (audit) plans To facilitate computerisation of records To provide legal evidence of what assessment (Ax) and treatment To allow easy retrieval of data & thus repetition and reassessment (Rx) took place

Issues surrounding records

Contents Confidentiality Security & Storage Data protection Act applies Ownership EHR Electronic health record (EPR) Access to health records

Core Standards Consists of:

What POMR notes should contain.

This advice is in keeping with the HPC standards Data base and complimentary to the Rules of Professional Problem list Conduct (CSP). Initial treatment plan (STG/ LTG)

Progress notes (SOAP or SOAPIER) Discharge summary of above when appropriate

CONSENT

You must gain & document informed consent It is unlawful to act in the best interests of the patient without consent.

Valid Consent Requires:

Having the capacity to make a particular decision Not be acting under duress or coercion Have received sufficient information about the nature and purpose of the proposed intervention to make a decision (the Bolam standard) That it is an ongoing process No-one can give consent on behalf of another adult.

1.

2. 3.

4. 5.

Exceptions for consent

Complex issues regarding children need to be discussed with employer or seek specialist advice from CSP, or solicitor. Treatment given to incapacitated adults without consent is only in cases of a) preservation of life b) the prevention of serious deterioration. Where there is a valid Certificate of Incapacity

Consent covers

Oral or written Consent to start Examination/Treatment Given treatment options benefits side effects Given opportunity to ask questions Pt informed of right to decline treatment at any stage ( fully documented if taken up) Pt informed they may be treated by or observed by a student but have the right to decline

Confidentiality Standard

Information given to the PT is in strict confidence

Information can only be released with the patients written consent i.e.. To Lawyers, employers

SOAPIER Notes

Subjective Objective Assessment/ Analysis Assessment /Analysis Plan Treatment Rx Intervention / Implementation Plan Evaluation Revision of Plan

Database

PC HPC PMH DH SH (Cautionary notes)

Subjective

Update of previous info/ relevant new info Info addressed in previously set goals Subjective response to treatment Patient compliance Level of function at home Relevant info that will assist the therapist Planning pts Rx & when to discontinue Info from ward handover/other professionals

Objective

History from medical records (anything pt has not said) Investigations (x-ray, blood tests, surgery) Measurable information Observable information Repeatable procedures Helps monitor progress and reassessment

Analysis/ Assessment Ax
Summary of patients major problems as found in S+O From S+O what is within normal limits Review S+O post Rx (inc side effects) Set priorities which you think are important for you & client List therapy problems in order of importance

Assessment (Ax) / Analysis Continued..

Assessment part of notes contains analysis of plans and goals for the patient Prioritise goals Justify decisions Discussion of patients progression in therapy Sometimes you can state a physical therapy diagnosis

Treatment (Rx)

The intervention/s What you did, how many times, with whom, where, when, equipment used, settings, effects..

What influences management of treatment???

Is there evidence of effectiveness?

Does the treatment make sense with what I know?

Time experience Clinical

Am I competent to carry the treatment out? Does anyone else need to be involved

How can I measure effectiveness of the treatment?

Prior experiences of the patient Resources

Does the patient consent to the treatment?

Plan

Plans for further Ax/ Reassessment For Pts treatment Plan for needed to What Rxdischarge achieve Short Term Goals and Long Term Goals Pt and family education e.g. what help Frequency per day / wk pt to be seen is needed with home exercises? pt will receive Treatment Equipment needs Location of Treatment Referral to other services

Treatment progression

GOALS

To help plan treatment to meet specific goals of the patient & therapist Prioritise Rx and measure effectiveness Assists with monitoring cost effectiveness Communicate therapy goals (function etc) S.M.A.R.T STG & LTG (short & long term goals)

How do we come up with problem lists?

Identifying the problem list Clinical reasoning process

Use problem solving skills

Patient centred

Discuss with patient!! Prioritised

Numbered Linked to goals/aims Linked to outcome measures

Remember we are physiotherapists not magicians!!

Delivery

Record all advice and information given to the patient sign and date it. Student notes must be signed by your educator Record equipment loaned to patient

Documentation
Errors crossed Each page numbered Provide detail of intervention given Patients name ,No. or d.o.b on each page Record of students countersigned Dictated notes must include date,name,typist& reference

Concise/legible Signed/dated Logical sequence Accurate

Name printed & signed after each entry No abbreviations unless agreed No correction fluid Permanent black ink

Security

Patients records are retained in accordance with current legislation (8yrs, 25yrs for obstetrics & children)

Kept in secure lockable cupboards Signature book kept so signatures are recognised and traceable

Relevant Legal Policies

Access to Health records Act(1990) Data Protection Act (1998) Health & Social Care Act (2001 Section 60) Public Records Act (1958)