Melbourne Health Policies, Procedures and Guidelines

Melbourne Health
Policies, Procedures and Guidelines
CLINICIAN GUIDELINES: Physiotherapy Documentation Guidelines - Internal Guidelines
__________________________________________________________________________________________________________________
Category:
Clinical Governance and Quality Management
Ref No.:
AHPT05
__________________________________________________________________________________________________________________
Sub-Category: Quality Improvement
Version No.: 1
__________________________________________________________________________________________________________________
Issue Date:
05 Mar 2015
Expiry Date: 19 Mar 2017
__________________________________________________________________________________________________________________
Department: Allied Health
DEPARTMENT
Allied Health - Physiotherapy
NAME OF DOCUMENT
Physiotherapy Documentation Guidelines – Internal Guidelines
NUMBER
AHPT05
SPONSOR
Executive Director of Nursing and Allied Health Services
FUNCTIONAL GROUP
Nursing and Allied Health Services, Physiotherapy
IMPLEMENTATION STRATEGY
Implementation of these guidelines will be achieved by:
 Dissemination of updated guidelines to all
Physiotherapy Staff via e-mail
 Discussion at site-based senior clinician meetings and
team meetings
 Publish in iPolicy
 Audit patient medical files against updated criteria
EVALUATION STRATEGY
Clinical documentation audit
EQuIP NATIONAL CRITERIA
Standard 14
VERSION SUMMARY
These guidelines outline the minimum standards for clinical
documentation expected of clinicians and allied health
assistants within Physiotherapy.
Documentation encompasses all written and/or computerised
recordings of all aspects of a patient‟s care that reflects what
was communicated, planned or provided to that patient.
1. ASSOCIATED MELBOURNE HEALTH POLICY
MH 05.01 Clinical Documentation
MH05 Documentation and Records Management
AH05.01 Allied Health Time Out and Consent Procedure
2. PURPOSE AND SCOPE
These guidelines outline the minimum standards for clinical documentation expected of clinicians and
allied health assistants within Physiotherapy.
These guidelines should be read in conjunction with MH 05.01 Clinical Documentation
MH05 Documentation and Records Management.
3. DEFINITIONS
Documentation
Documentation encompasses all written and/or computerised recordings
of all aspects of a patient‟s care that reflects what was communicated,
planned or provided to that patient
4. RESPONSIBILITIES
4.1.
Executive Director of Nursing and Allied Health Services
4.2.
Director of Allied Health
4.3.
Allied Health Physiotherapy Manager
4.4.
Physiotherapy Clinical Staff – clinicians and allied health assistants
4.5.
Physiotherapy Research staff – honorary and employees
__________________________________________________________________________________________________________________
Authorised by: Director Allied Health
Document upload on 23 Mar 2015
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*NOTE - Printed or downloaded version are uncontrolled and subject to change*
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CLINICIAN GUIDELINES: Physiotherapy Documentation Guidelines - Internal Guidelines
__________________________________________________________________________________________________________________
Category:
Clinical Governance and Quality Management
Ref No.:
AHPT05
__________________________________________________________________________________________________________________
Sub-Category: Quality Improvement
Version No.: 1
__________________________________________________________________________________________________________________
Issue Date:
05 Mar 2015
Expiry Date: 19 Mar 2017
__________________________________________________________________________________________________________________
Department: Allied Health
5. GUIDELINE
Physiotherapy - Clinical Staff
Inpatient Physiotherapy Documentation:
The following information should be written in the patient medical record during an inpatient episode.
5.1 Initial Contact:
Clinical staff must document:

Patient ID verification using the Time Out process

Reason for, and source of, the referral

Relevant past medical history

Pre-morbid function

Consent (oral or written) obtained and documented

Brief subjective assessment – may include nursing handover details regarding any changes to patient
status

Brief objective assessment - observations, as required; respiratory status, as required; mobility status;
precautions/contraindications (incl. post-op orders)

Intervention/recommendations

Plan for further assessment and/or treatment

if full assessment is not undertaken at the time, provide brief explanation outlining reason.
5.2 Initial Assessment Documentation:
Clinical staff must document the following information:

Initial assessment documented based on SOAP format.

Subjective examination (symptomatic)

Objective examination (measureable, observable)

Action/Analysis (interpretation of current condition/intervention provided)

Plan of action

Written or verbal feedback to the client or other relevant carers

Discharge plan documented

Agreement to treatment plan by patient or „person responsible‟
5.3 Progress Documentation
Progress documentation may include the following information:

Any individual intervention should be documented in SOAP format (including response to intervention/s
using outcome measures)

Oral consent obtained and documented when there is a significant change in treatment/ treatment
options/ status of patient‟s health.

Written consent obtained for designated invasive procedures

Change in status or events that may affect discharge plans/goals

Documented consultation with key clinical team members

Discharge planning activities
__________________________________________________________________________________________________________________
Authorised by: Director Allied Health
Document upload on 23 Mar 2015
Page 2 of 4
*NOTE - Printed or downloaded version are uncontrolled and subject to change*
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CLINICIAN GUIDELINES: Physiotherapy Documentation Guidelines - Internal Guidelines
__________________________________________________________________________________________________________________
Category:
Clinical Governance and Quality Management
Ref No.:
AHPT05
__________________________________________________________________________________________________________________
Sub-Category: Quality Improvement
Version No.: 1
__________________________________________________________________________________________________________________
Issue Date:
05 Mar 2015
Expiry Date: 19 Mar 2017
__________________________________________________________________________________________________________________
Department: Allied Health
5.4 Discharge

Patient condition, and functional level on discharge (subacute inpatients only)

Recommendations and actioned referrals for further management (if required)

State discharge destination (if appropriate)

Equipment and resources supplied, including funding source (if appropriate)
5.5 Outpatient Physiotherapy Documentation
Initial assessment, progress and discharge notes to be documented using the outlined format as appropriate..
City Campus:
Outpatient physiotherapy initial assessment and progress notes remain in the Physiotherapy
Department and filed in the medical record on discharge.
Physiotherapy – Allied Health Assistant (AHA) Staff
The AHA documents observations and interventions completed with a patient and should not “interpret” or
“analyse” the session in their notes.
AHA documentation is to be the SOAP format as outlined below:
Subjective Assessment: this is what the patient reports to the AHA eg: how they are feeling, problems or
changes that have occurred
If any issues are raised by patient, the AHA documents in „plan‟ section „issue to be followed up with treating
physiotherapist‟
Objective Assessment: this is what the AHA observes throughout the session with a patient
If an issue is observed, the AHA documents in „plan section‟ „issue to be followed up with treating
physiotherapist‟
Action: this is the intervention completed with the patient/treatment session – documentation should read
„Intervention carried out as per physiotherapist treatment plan‟
Plan: AHA documents when they plan to see the patient again, any instructions for other staff - documentation
should read „Continue with daily treatment plan‟ or „Review as required by physiotherapist‟
Student Documentation
It is a requirement that students undertaking student placements document assessment and intervention in
the patient‟s medical file. Documentation requirements for students are the same as for clinical staff.
Clinicians supervising students should ensure students adhere to the Physiotherapy Documentation
Guidelines and are expected to countersign all student entries.
Documentation Frequency – refer to MH 05.01 Clinical Documentation
6. ASSOCIATED POLICIES/PROCEDURES/GUIDELINES
MH 05.01 Clinical Documentation
MH05 Documentation and Records Management
AH05.01 Allied Health Time Out and Consent Procedure
MH02.02.01 Consent
MH 01 Access Policy
MH01.02 Patient Identification
__________________________________________________________________________________________________________________
Authorised by: Director Allied Health
Document upload on 23 Mar 2015
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*NOTE - Printed or downloaded version are uncontrolled and subject to change*
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CLINICIAN GUIDELINES: Physiotherapy Documentation Guidelines - Internal Guidelines
__________________________________________________________________________________________________________________
Category:
Clinical Governance and Quality Management
Ref No.:
AHPT05
__________________________________________________________________________________________________________________
Sub-Category: Quality Improvement
Version No.: 1
__________________________________________________________________________________________________________________
Issue Date:
05 Mar 2015
Expiry Date: 19 Mar 2017
__________________________________________________________________________________________________________________
Department: Allied Health
MH02.07.02 Surgical Site and Invasive Procedure Confirmation
7. FURTHER INFORMATION
7.1.
Director of Allied Health
7.2.
Manager Physiotherapy
8. REVISION AND APPROVAL HISTORY
Date
January 2015
Version
1
Author and approval
Stella Kravtsov, Allied Health Workforce Development Manager
(Physiotherapy); Samantha Plumb, Physiotherapy Manager
__________________________________________________________________________________________________________________
Authorised by: Director Allied Health
Document upload on 23 Mar 2015
Page 4 of 4
*NOTE - Printed or downloaded version are uncontrolled and subject to change*
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