Physical Therapy and Chiropractic

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Outlined below are some of the stringent physiotherapy and chiropractic criteria the eNoteFile team aimed to satisfy with eNoteFile’s unique functionality.

We know elements of these concepts are universal across other professions within allied health / rehab, such as occupational therapy, podiatry, speech pathology, orthotics and prosthetics, and psychology.

Informed dynamic consent

"Clients may find it helpful to receive standard written information or diagrams. Informed consent is dynamic... if a new or altered intervention is provided then the health professional needs to seek the client’s consent again." pp. 14-15.

Documenting consent

"Physiotherapists must document that an appropriate consent process has taken place. The best evidence is a (client) signed and dated entry in the client health record..." p. 15.

Legibility

"Records must be legible to enable optimal health care and to be admissible as evidence, if required... this means someone other than the author must be able to decipher entries." p. 28.

Signature compliance

"For hard copy records, the date and signature of the treating health professional is required for each separate entry in the health record. For electronic records, initials may suffice as long as it is clear which health professional treated the client." p. 29.

Correction

"Corrections must be signed and dated" p. 29.

Referrals

"Where a client is referred to another health professional... a copy of the referral should be kept in the client’s health record."p. 31 (see also assessment indicator P on pg 32 and A on pg 36).

Audits

"Audits should include a sample of between 5 and 15 client health records from clients discharged in the period since the previous audit (which should be no longer than six months) p. 31.

Professional communication

"...professional written communication should be on practice letterhead" p. 36.

Information technology systems

"...the practice should have at least a basic level of computerisation including backup systems." p. 41.

Practice Communication

There are agreed systems to ensure physiotherapists (and other allied health professionals if in a multidisciplinary practice) communicate important information to all relevant staff effectively eg email bulletins, practice newsletters. There is a policy for communicating test results in a timely manner. p. 43.

Collection consent

"...if a client presents to a physiotherapist and discloses health information which is written down by the physiotherapist during the consultation, this will generally be regarded as the client giving implied consent to the physiotherapist to collect health information for certain purposes." p. 50.

Storage

"The practice must store both active and inactive (client not attended for at least 2 years) health information records securely. (It) must take reasonable steps to protect the health information it holds from misuse and loss as well as from unauthorised access, modification or disclosure. Health information, whether in hard or electronic copy, should be controlled and restricted to relevant staff. Where health information is kept in electronic copy, the practice should have adequate IT support. Culling of inactive client health records from the main filing system is permitted where it improves the efficient management of health information." p. 52.

Retention

"Guild insurance, which offers the insurance policy recommended by the APA, suggests that where possible client health records should be kept in perpetuity. Alternatively, Guild suggests that as a minimum, records should be held for 10 years; or in the case of minors, 10 years from the date they turn 18. Guild also cautions that statutes of limitations can be extended depending on the nature of the incident." p. 52.

Security

"If the practice uses computers to record and store client’s health information there are personal passwords to authorise appropriate levels of access to health information, screensavers, regular backups, secure offsite storage..." p. 53.

Disclosure

"Practices should not transfer client information by email unless it is encrypted." p. 55.

Access to evidence

"...the practice should provide at least basic access to tools such as the internet... APA website... (for online access to evidence-based research)" p. 83.

Outcome measures

"The treating physiotherapist should be using outcome measures to systematically note changes in the client’s health status... Such changes should be documented in the client health record and be relevant to the client’s presenting condition..." p. 85.

Outcome data

"To help the practice deliver consistently high quality physiotherapy, practices are encouraged to review outcome data on a regular basis... eg for clients with a particular condition, and compare the practice results with recognised best practice to identify areas for clinical improvement." p. 85.

Alterations to patient records may be necessary in physiotherapy - however for reasons of integrity, you should record the change and note the user, date and time. eNoteFile can do this automatically.

Your computer system can be automatically logged off after a set period of inactivity so the likelihood of unauthorised access is lessened, unlike paper notes.

To use Guild Group’s RiskMASTER assessment tool

• Click on RiskMASTER link or Riskequip

Remember, eNoteFile can be tailor made to suit your organisation as part of a customised solution.