PO-006.01:Physical Therapy Administration

1. PO-006.01:Physical Therapy Administration

2. Learning Objectives • The physical therapy technician will participate as a member of the physical therapy administration team by: • Developing a plan for patient charting • Adhering to patient charting procedures • Review charting standards and guidelines • Explain the importance of confidentiality • Explain the role of the medical records department • Explain and implement patient chart storage

3. PT Charting Review Quiz • What is the acronym for PT charting? • What does each letter stand for? • What letter does each of the following pieces of patient information go under? • “ROM knee: flexion=130º, Extension= -10º” • “I feel a deep aching pain in my back every morning” • “Tolerated treatment well. Pain now 2/10” • “Applied TENS as per treatment plan” • “Diagnosed with disc herination” • What form must be completed and put into a patient’s chart on their first visit and again at discharge?

4. Quiz Answers • SOAPIE • S=Subjective, O=Objective, A=Assessment, P=Plan, I=Intervention, E=Evaluation • a) O b) S c) E d) I e) A • The appropriate outcome measure

5. PT Charting Review • As taught in PO 002, charting is essential as it is the permanent record of the care that a patient received • It is the way health care professionals communicate with each other • WCPT indicates that: • The physical therapist clearly documents all aspects of patient/client management including the results of the initial examination/ assessment and evaluation, diagnosis, prognosis/plan of care, intervention/treatment, response to interventions/treatments, changes in patient/client status relative to the interventions/ treatment, re-examination and discharge/discontinuation of intervention, and other patient/client management activities

6. Charting Continued . . . • PTTs ensure that the contents of charts: • Are accurate, complete, legible and finalized in a timely manner • Are dated and appropriately authenticated by the physical therapist • Record equipment loaned and/or issued to the patient/client • Include the status of the patient/client if discharged prior to achievement of desired goals and outcomes, and the rationale for discontinuation • Include reference to appropriate outcome measures, when possible

7. Confidentiality • The principle that the information a patient reveals to a health care provider is private, and can only be disclosed to a third party under certain clearly defined circumstances • Patients expect health care professionals involved in their care, or who have access to information about them, to protect their confidentiality at all times • This information might include details of a patient’s lifestyle, family or medical condition that they want kept private

8. Patient Confidentiality • The principle of maintaining the security of information elicited from an individual in the privileged circumstances of a professional relationship • An ethical duty to maintain patient confidentiality, which allows the patient to comfortably make a full and frank disclosure of information with the knowledge that it will be protected • A PT/PTT may not disclose any medical information revealed by a patient, or discovered in connection with the treatment of a patient

9. Charting Confidentiality • Physical therapists make sure that documentation is used properly by ensuring it is: • Stored securely at all times in accordance with legal requirements for privacy and confidentiality of personal health information • Only released, when appropriate, with the patient’s/client’s permission • Consistent with reporting requirements • Consistent with international and national data standards where possible

10. Principles of Confidentiality • To maintain confidentiality, PTTs should: • Take all reasonable steps to keep information about patients safe • Get the patient’s informed consent if before passing on their information • Only disclose patient information if it is absolutely necessary, and, when it is necessary, only disclose the minimum amount necessary • Inform patients when their information has been disclosed

11. Record Storage • To maintain confidentiality of patient records, it is essential to protect the records from being lost, damaged, accessed by someone without appropriate authority, or tampered with • This means that reasonable steps need to be taken to protect patient records • For example, storing records in a locked container when not in use

12. Storage Guidance • Records pertaining to the patient shall be kept in chronological order, for the minimum time required for storage of records in accordance with national legislation and/or local guidelines • Procedures should comply with local/national requirements for periods of storage and destruction processes

13. Medical Records Department • Major function is to be the custodian of patient’s medical record/chart, and to provide prompt and efficient service to users • The hospital administration is responsible for seeing that the medical records department of their institution has adequate facilities and equipment for efficient day-to-day operation of the service

14. Med Records Continued . . . • There should be sufficient storage space for medical records to allow for future storage needs • Areas for active and inactive medical record storage should be sufficiently secure to protect records against loss, damage, or use by unauthorised persons

15. ANA Med Records • Active charts are kept in a secure location in the PT department and locked when not in use • Currently, PT records are held in the PT department until the patient is discharged • The files are then transferred to the med records department at NMH and stored

16. Record Disposal • Destruction of records shall be done in accordance with national legislation and the policies and/or guidelines of the practice or institution • Such policies should make provisions for the period of time that records should be held, who is responsible for records disposal and the procedures for disposal

17. Summary • Charting is essential, as it is the permanent record of the care that a patient has received, and is the way health care professionals communicate with each other • The information a patient reveals to a health care provider is private, and can only be disclosed to a third party under certain clearly defined circumstances • A PT/PTT may not disclose any medical information revealed by a patient, or discovered in connection with the treatment of a patient, without consent • To maintain confidentiality of patient records, it is essential to protect the records from being lost, damaged, accessed by someone without appropriate authority, or tampered with • Destruction of medical records shall be done only in accordance with national legislation and the policies and/or guidelines of the practice or institution

18. Questions?

19. Comprehension Check • What is patient confidentiality? • Why is this principle important for the development of the professional relationship with the patient? • How should medical records be stored? • What are the main function of the medical records department? • How is the destruction of medical records to be carried out?

20. Answers • The principle that the information a patient reveals to a health care provider is private, and can only be disclosed to a third party under certain clearly defined circumstances • It allows the patient to comfortably make a full and frank disclosure of information with the knowledge that it will be protected • In a secured area, with controlled access, in chronological order, for the minimum time required for storage of records in accordance with national legislation and/or local guidelines • to be the custodian of patient’s medical record/chart, and to provide prompt and efficient service to users • in accordance with national legislation and the policies and/or guidelines of the practice or institution