PO-006.01:Physical Therapy Administration

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

PT Charting Review Quiz

1. What is the acronym for PT charting?2. What does each letter stand for?3. What letter does each of the following pieces of patient

information go under?a) “ROM knee: flexion=130º, Extension= -10º”b) “I feel a deep aching pain in my back every morning”c) “Tolerated treatment well. Pain now 2/10”d) “Applied TENS as per treatment plan”e) “Diagnosed with disc herination”

4. What form must be completed and put into a patient’s chart on their first visit and again at discharge?

Quiz Answers

1. SOAPIE2. S=Subjective, O=Objective, A=Assessment,

P=Plan, I=Intervention, E=Evaluation3. a) O

b) Sc) Ed) Ie) A

4. The appropriate outcome measure

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

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

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

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

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

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

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

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

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

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

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

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

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

Questions?

Comprehension Check

1. What is patient confidentiality?2. Why is this principle important for the

development of the professional relationship with the patient?

3. How should medical records be stored?4. What are the main function of the medical

records department?5. How is the destruction of medical records to

be carried out?

Answers

1. 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

2. It allows the patient to comfortably make a full and frank disclosure of information with the knowledge that it will be protected

3. 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

4. to be the custodian of patient’s medical record/chart, and to provide prompt and efficient service to users

5. in accordance with national legislation and the policies and/or guidelines of the practice or institution