In most Western countries, record keeping and accurate documentation by physiotherapists are not only professional, but also a legal obligation. However, in some countries where physiotherapy is not a regulated profession, there is not much emphasis on accurate record keeping.
Abdelrahman (2014) define medical records as “..as handwritten clinical notes, …… emails, scanned records, consent forms, text messages, verbal correspondence between health professionals, laboratory results, X ray films, photographs, video and audio recording, and any printouts from monitoring equipment”.
Despite its importance, clinical record keeping is often given a low priority. It is common to find illegible entries, offensive comments and missing information, and there is often inconsistency between the entries by different healthcare professionals. Information in medical records should be documented on a daily basis and in chronological order demonstrating continuity of care and response to treatment. The information should be comprehensive enough to allow someone else to take over the care if needed.
In this article, a brief summary of guidance is provided along with a sample assessment report. At the end of article, links to other detailed guidance available are provided for further reading.
What should be recorded?
There is a wide variability in what physiotherapists document as a part of their record keeping. From some physios keeping meticulous records of all their interactions, thought process, clinical reasoning, goal planning, interventions and outcome measurements, to others maintaining summary notes on the clinical encounters.
CSP guidance on record keeping states that “a good record will provide evidence of the nature of conversations you have had with your patient, the extent of any exam you have performed, what treatment was provided and your clinical reasoning for the decisions you have made.”
One of the most common standardised formats for recording clinical encounters is the use of SOAP format. A SOAP note consists of four sections including subjective, objective, assessment and plan. Most electronic health record systems have templates that plug information into the SOAP notes format.
What is SOAP format?
The first part of a SOAP note is Subjective. This refers to the subjective history and observations reported by the patient. It is called subjective as these are self-reported and therefore usually can not be objectively measured. For example, the level of pain reported by patients.
Within subjective history it is important to note the current presenting complaint (also called as chief complaint), its SIN (severity, irritability and nature), location, duration, variability, aggravating and alleviating factors, associated symptoms. It is also important to record any co-morbid conditions and relevant past medical history. Depending on the type of assessment, further information may also be sought in terms of patient’s perceived impact of condition on physical, psychological or social aspects of their live (bio-psychosocial model).
The second section of SOAP notes is Objective which includes all objective tests and physical examination. The aspects usually covered in physiotherapy objective notes may include active or passive range of motion, strength, sensory testing or any special tests. These tests vary by the clinical need and presentation of the patient, however, there are common elements which are covered for specific subgroups e.g. musculoskeletal exam, orthopaedic exam, paediatric exam.
Assessment section comprises the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. The diagnosis may be formal medical diagnosis or in physiotherapy, it may be a functional diagnosis (highlighting the functional abilities and limitations). The assessment section is also provides space for documentation of clinical reasoning and thought process of the physiotherapist as they process the information gleaned through subjective and objective assessment and develop a differential diagnosis and undertake the decision making to arrive at their assessment of the patient’s condition.
As the name denotes, plan refers to rehabilitation planning which may include further testing, investigations (if relevant) or interventions to be provided. It is generally good practice at initial assessment to set short and long term goals (depending on practice settings) within the plan section. It is good practice to agree the goals with the patient to ensure they are patient-centred and relevant to them. The next step within planning is to develop a list of activities or interventions which will be provided to the patient to achieve the goals.
SOAP format can be used for initial assessments, follow up sessions or discharge reporting. Whilst detailed history and assessment is undertaken and reported at initial assessment, the notes in follow up sessions focus on the change in subjective patient reporting of symptoms, any further tests and physical re-examination conducted. The assessment and planning sections likewise focus on any additional reasoning, goals or planned interventions.
Best practice guidance
The “Good Medical Practice” guidelines issued by the General Medical Council UK clearly state that clinical records represent the formal record of a clinician’s work and must be clear, accurate, legible and written in a scientific manner. The key recommendations from the Royal College of Physicians as well as the CSP’s record keeping guidance are presented below. Similar guidance is provided by other countries, such as Australia (Health Practitioner Regulation (NSW) 2016), most of the United States, France and many others.
- Every service user who receives physiotherapy should have an appropriate healthcare record. Records are set up at the time of initial contact, written up at the completion of clinical encounter or before the end of that working day.
- Records are stored and disposed off according to the legal requirements.
- Records should be are legible, factual, consistent and accurate such that service users and other health professionals can understand the content.
- Data capture systems are designed and maintained to provide effective and secure transfer of patient identifiable information. Systems are configured to meet information governance standards around maintaining the security and confidentiality ofservice user identifiable data, including encryption of emails and use of mobile/portable device.
- The contents of the medical record should have a standardised structure and layout.
- Consent should be appropriately obtained and recorded within the records. While verbal consent has equal force as written consent for the clinical encounter, for interactions and disclosure of patient related information with other stakeholders, written consent must be obtained.
- Documentation within the medical record should reflect the continuum of patient care and should be viewable in chronological order.
- Every entry in the medical record should be dated, timed (24 hour clock), legible and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be countersigned, dated and timed.
- Entries to the medical record should be made as soon as possible after the event to be documented (e.g. change in clinical state, ward round, investigation) and before the relevant staff member goes off duty. If there is a delay, the time of the event and the delay should be recorded.
- An entry should be made in the medical record whenever a patient is seen by a clinician or the clinician undertakes another activity related to patient care e.g. send referral or contact employer etc.
Benefits of good record keeping
The principal benefits of good record keeping are:
- Provides documentary evidence of the services provided
- Supports continuity of care
- A shared health record provides basis of multi-disciplinary collaboration
- May help identify risks and complications
- Supports research, audit, performance management and resource allocation
- Is evidence in case of a complaint or in the legal process.
CSP’s record keeping guidance – https://www.csp.org.uk/system/files/publication_files/PD061%20Version%203.2%20Record%20Keeping%20Guidance.pdf
PRSB’s standards for Structure and Content of the Health and Care Record – https://theprsb.org/wp-content/uploads/2019/02/3950-PRSB-digital-PDF-web.pdf