Is Your Documentation Up To Standard

Mar 8, 2022

Would your documentation meet the standards if tested and do you know what the standards are?

As therapists we recognise how important documentation is and many are aware of cases and instances of “if it isn’t written down it didn’t happen”, but do we know:

  1. What do our professional standards and regulations request?
  2. What format should the documentation follow?
  3. Would our electronic records meet the standard?
  4. Are abbreviations acceptable in our documentation?
  5. What is a subject access request?

Consider your responses to the above and then read on…

Let’s start with the overarching statement from the HCPC.

Once you are registered with us, you have a professional responsibility to keep full, clear, and accurate records for everyone you care for, treat, or provide other services to. 1

The HCPC states the practice and format is likely to be specific to your profession and your place of work. An overview of their standards to be followed: –

  • Documentation must enable continuity of care and provide information for other clinicians involved in the care and treatment.
  • All records must ensure the treatment is in the service user’s best interests.
  • Records must meet legal requirements or respond to Freedom of Information or Subject Access Requests.
  • Must evidence your decision-making processes if later queried or investigated.
  • Kept safe from any inappropriate access: The system used is not mandated but it must have password protection if electronic or locked securely if paper. How often is if the key/password easy to find?

The documentation needs to meet specifics within the below HCPC standards.

The HCPC standards of performance, conduct and ethics2 stipulate: –

  • You must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to (10.1).
  • You must complete all records promptly and as soon as possible after providing care, treatment, or other services (10.2).
  • You must keep records secure by protecting them from loss, damage, or inappropriate access (10.3).

Whereas the HCPC Standards of Proficiency3 stipulate you must: –

  • Be able to maintain records appropriately (10).
  • Be able to keep accurate, comprehensive, and comprehensible records in accordance with applicable legislation, protocols, and guidelines (10.1).
  • Recognise the need to manage records and all other information in accordance with applicable legislation, protocols, and guidelines (10.2).

Let’s consider some key record documentation standards and requirements of the Chartered Society of Physiotherapy4

  • They do not stipulate the format of the notes, this is for the individual to decide and may differ depending on the system being used.
  • Written records must be legible, in black ink, signed and dated and a record of signatures must be kept.
  • Physiotherapy staff have a professional and legal obligation to keep an accurate record of any interaction with a patient which needs to illustrate: –
  1. The informed consent process was followed5
  2. There is an evidenced and reasoned treatment plan which includes
  3. An explanation of the risks to the patient
  4. An explanation of the benefits to the patient
  5. Agreement and understanding of the above by the patient
  6. That where possible shared decision making occurred
  7. If capacity was impaired how the shared decision-making process was determined
  8. That timed goals were agreed
  9. That appropriate outcome measures are being used
  10. Any problems that arose during assessment or treatment are documented and any actions taken to address them
  11. That appropriate standard coding techniques and protocols are used
  12. Any short forms and abbreviations are standardised for the service6
  • This interaction must be contemporaneous in nature. In law “a contemporaneous record means any document created at or around the time of the event that is recorded in the document.” This means to be deemed contemporaneous the entry into the note’s documentation must clearly be both timed and dated.
  • Mistakes must not be obliterated. Any mistake must be dated, timed, and signed. If using an electronic record, could your electronic system evidence this?  Or does your electronic system simply allow permanent deletion of the mistake? Does it lock the notes to a single password protected user and documents their access7?
  • Subject access requests – these can be exercised by a patient under GDPR rules to see what information an organisation is holding about them. A request must be made in writing to see the documentation and must be actioned in 30 days. A charge is not usually made, and a process should be in place which includes checking the identity and validity of the person making the request.

When reviewing your documentation process also consider the wider implications of creating and holding records.

Remember that the records should be accessed, retained, stored, transported, and destroyed according to the legal requirements and policies should also exists to determine this.

But we will save all those considerations to another post on another day!

Thanks for taking the time to read this far and we invite you to revisit the initial 5 questions and now ask – can I answer these and do I comply?

If not, or still not sure, we are always here to help.

Why not join us on Zoom to discuss documentation on 21.3.22 at 6.30pm -7pm.

Available to buy in our store for £10.

Choose Monday Musings March (Third Monday of the Month).

 

Additional reading

 

References

  1. HCPC Meeting Our Standards Record Keeping
  2. HCPC Standards of Conduct, Performance and Ethics
  3. HCPS Standards of Proficiency
  4. Chartered Society of Physiotherapy Quality Assurance Standards for Service Delivery (Section 6)
  5. Understanding Informed Consent: A Guide for Clinicians
  6. HCPG would advise this abbreviation document is sent with any subject access request to enable understanding by a non-medical reviewer.
  7. Chartered Society of Physiotherapy Record Keeping Guidance PD061 Jan 2021

To stay up to date with HCPC compliance click here.