Element: List at least 3 factors which could indicate the need to cease or modify the treatment What do I need to write in the patient file? Element: Record Information from session in patient file in a timely manner in line with relevant polices and procedures Each organisation you work for will have individual requirements for documentation. Ask you supervisor to show you the documentation requirements/policy when you first start. Below are some general tips for documenting in a patients file: Do Don’t Record the date and the time at the beginning of Do not to add your opinion or interpretation of the entry events into the notes Sign each entry with your surname and Under no circumstances should documentation designation (AHA) clearly printed be destroyed or deleted. Document any changes made to the original plan Leave blank spaces in a patient file. Any unused set our by the AHP e.g. unable to complete writing spaces must be filled in with a single ‘Was therapy session as planned due to fall prior to horizontal line. AHA arrival’ Do not use subjective or defamatory statements Be brief and factual Use approved abbreviations Write neatly and legibly Any errors made in patient medical records must have a single line drawn across the applicable area. The person responsible will write: “Entry made in error” and then sign in the usual manner Documentation information related to involvement of the patient/carer in care planning Your turn… Using the SOAP format write a progress note for a patient you have observed during orientation
Element: List at least 3 factors which could indicate the need to cease or modify the treatment What do I need to write in the patient file? Element: Record Information from session in patient file in a timely manner in line with relevant polices and procedures Each organisation you work for will have individual requirements for documentation. Ask you supervisor to show you the documentation requirements/policy when you first start. Below are some general tips for documenting in a patients file: Do Don’t Record the date and the time at the beginning of the entry Sign each entry with your surname and designation (AHA) clearly printed Document any changes made to the original plan set our by the AHP e.g. ‘Was unable to complete therapy session as planned due to fall prior to AHA arrival’ Be brief and factual Use approved abbreviations Write neatly and legibly Any errors made in patient medical records must have a single line drawn across the applicable area. The person responsible will write: “Entry made in error” and then sign in the usual manner Documentation information related to involvement of the patient/carer in care planning Do not to add your opinion or interpretation of events into the notes Under no circumstances should documentation be destroyed or deleted. Leave blank spaces in a patient file. Any unused writing spaces must be filled in with a single horizontal line. Do not use subjective or defamatory statements Your turn… Using the SOAP format write a progress note for a patient you have observed during orientation