Week 4 Flashcards
Purposes of record keeping?
1) Legal protection
2) Continuity of care
3) Quality improvement
4) Communication
5) Ethical responsibility
All clinical records must be
1) Organized
2) Understandable
3) Accurate
What is mandatory for a patient’s file to have?
a signature sheet:
form in a patients file that outlines
- each team members name
- designation
- signature and initials
T/F: Therapist needs to co-sign OTA/PTA charts
False
T/F: OTA/PTAs can make chart entries in patient files if they decide to do so
False
OTA/PTA can make a chart entry ONCE therapist deems it appropriate and have assessed the assistant’s skill set
OTA/PTA charting regulations:
OTA/PTA can make a chart entry ONCE therapist deems it appropriate and have assessed the assistant’s skill set
Therapist does not need to co-sign
Making changes to a record:
never use White-Out or scratch it out, put a streak through the error and initial and date beside it
when using an electronic record, never delete an entry
you can use addendum, or late entry if you need to add something
Can write draft before writing in chart so others know that note has not been completed yet
In some cases, you have 5 days to complete a note/chart
What d you do when you mae a mistake in a chart?
never use White-Out or scratch it out, put a streak through the error and initial and date beside it
If you need to go back a while and add something to a previous patient chart, what do you do?
you can use addendum, or late entry if you need to add something
What is necessary to have in EACH patients file?
OT/PT working with assistants must have a written communication protocol in the file of each patient
Outlines how the assistant and the OT/PT will communicate in regard to the patient
MUST be signed by the OT/PT and the assistant working with the patient
What are important details to include in patient handouts?
Patient name and DOB
Date the handout was given to the patient
Condition for which the exercises/therapy was prescribed
Instructions on how to complete the activity including:
- number of repetitions/sets
- frequency and duration
-What should be felt or experienced
- Negative effects, when to stop
- Your name and contact information should they have questions
How long do you need to hold onto a patient’s file after a patient permanently leaves
10 years for an adult patient
10 years beyond when a patient turns 18 (pediatric: ten years after they turn 18)
Charts need to be stored in a secured area that can be locked
Charts need to be shredded and destroyed after the retention period has passed
S or O: - The patient states his goal is to return to work ASAP
S
S or O:The patient complains of left wrist pain
S
S or O: The patient’s pain is rated as 8/10
O
