All Wales Speech And Language Therapy Managers Committee
Pwyllgor Rheolwyr Therapi Iaith A Lleferydd Cymru Gyfan
Case note
Guidelines
For
Adult SLT Staff
Amended 6th June 2012Ratified By: / Signature:
Date of Issue: / Date of Review: / Guideline No: / 7
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INTRODUCTION
This paper sets out guidelines and standards for case note keeping within Speech and Language Therapy and has been ratified by the All Wales Speech and Language Therapy Managers Committee. It draws heavily on the Royal College of Speech and Language Therapists guidelines and Code of Professional Conduct.
The guidelines have been prepared by the Adult Services Committee and are for the use of all speech and language therapy services across Wales. They are not intended to replace Trust policies but do allow for common standards which can then be monitored on an All Wales basis.
The All Wales Speech and Language Therapy Managers Committee intends this guidance to allow each service to have clear standards of case note keeping in line with the Data Protection Act (1998) and RCSLT guidance that can be audited on a regular basis.
Evidence indicates that inadequate and inappropriate record keeping can neglect the interest of clients through:
a) Impairing the continuity of care;
b) Impairing communication between staff;
c) Failing to focus attention on early signs of deviation from the norm;
d) Failing to place on record significant observations and conclusions.
PURPOSE
Case notes are necessary to ensure continuity of care; client safety; communication with colleagues; evidence of practice and as a legal requirement. A record is required for every client and it is to be managed by the appropriate speech and language therapist.
The function of case notes is to:
1) Provide accurate, current, comprehensive and concise information concerning the condition and care of the client, source of and reason for referral;
2) Provide a record of any problems that arise and the action taken in response to them.
3) Provide evidence of care required; intervention by practitioners; and the client responses.
4) Record the chronology of events and the reasons for any decisions made.
5) Provide a baseline record against which change can be judged.
6) Act as a tool for reflection on practice and evaluating and auditing its effectiveness.
7) Act as a legal record of care, enabling the rationale for decisions to be identified even after long periods of time.
8) Aid communications with other professionals.
STANDARDS FOR CASE NOTES – KEY FEATURES
Properly made and maintained records will:
1) Be made as soon as possible after the events to which they relate;
2) Identify factors which jeopardise standards or place the client at risk;
3) Provide evidence of need, in specific cases, for practitioners with specialist knowledge and skills;
4) Provide details of other profession/agency involvement;
5) Aid client involvement in their own care and demonstrate that issues surrounding confidentiality have been reviewed and appropriate records made;
6) Provide protection for staff against any future complaint;
7) Wherever possible, be written in terms which the client will be able to understand;
8) The originator will ensure that entries are accurate and factual.
The best practice principles of recording information are:
1) Legibility
2) Timeliness
3) Accuracy
4) Completeness
5) Provision of an audit trail
AUDIT/MONITORING (QUALITY CONTROL)
It is essential to ensure that records are completed and stored in such a way as to facilitate the best interests of the client and enabling the provision of care and the promotion of health.
They should also be kept in such a manner as to facilitate audit, the investigation of complaints and the monitoring of quality standards.
The Guidelines for staff re: case notes audit sheet (see appendix 1) should be completed by staff as part of the audit process.
REFERENCES
Department of Health (1990) Access to Health Records Act (1990) A Guide for the NHS, Government Health Departments London, HMSO
Royal College of Speech and Language Therapists (2006) Communicating Quality 3.
Royal college of Physicians (2007) Generic medical record-keeping standards
ADULT SPEECH AND LANGUAGE THERAPY
CASE-NOTE STANDARDS-AUDIT FORM
Patient’s Name: ______DOB: ____/____/____
Treatment Location: ______Date Checked: ____/____/___
Name of Therapist: Date of feedback to therapist: ____/____/___
(method of audit to be decided locally)
Standard / ü / x / Comments1 / Clearly written and legible.
2 / Up-to-date. Contemporaneous, Written within 24 hours.
3 / Black ink.
4 / Each entry signed.
Full name and designation legibly printed against signature.
Method of identification of signatories and roles evident on front sheet.
5 / Where entries are made by a Speech and Language Therapy Assistant/support worker or Student, on behalf of therapist – this must be indicated, signed and counter-signed by supervising therapist.
6 / Errors are crossed out with a single line and signed and dated.
7 / Evidence of consent gained and documented on each intervention.
8 / Client’s language of choice recorded on front sheet
9 / P Number is recorded on front sheet
10 / Patient or NOK phone number included
11 / GP is included on front cover
12 / If abbreviations used are not included on the abbreviation list, write in full with the abbreviation along side it.
13 / Medical diagnosis is included on front cover
14 / S< diagnosis has been clearly recorded on front cover
15 / CT Scan results dated and recorded in relevant section of case history form
16 / Date of admission of inpatients is included inside as marked/date of referral clearly documented.
17 / Reason for admission is documented and presenting condition on admission
18 / Impression Diagnosis is documented in notes as appropriate. (This may change following investigations or time and should be altered accordingly)
19 / Past medical History is documented.
20 / Notes are in chronological order
21 / Each sheet is numbered
22 / Each continuation sheet/assessment sheet contains client’s full name and NHS number.
23 / Gaps in notes scored through and initialed
24 / Clear notes about past therapy/treatment given.
25 / Discussions (direct or indirect) with relatives/Dr’s etc are documented and dated and signed as above.
26 / The time of appointment/assessment/telephone contact is included for every intervention using 24 hour clock.
27 / Each intervention states specifically if a relative/carer was present during the session and their name.
28 / Indirect contacts are recorded and dated
29 / A risk management form included in the notes if relevant and a red triangle on the top left corner of the notes indicates its presence.
30 / Include relevant medications (or state that medications are listed in medical notes) and allergies recorded
ASSESSMENTS
31 / Location where patient seen is documented eg. IP, OP, HV
32 / Relevant Assessments have been completed – There is evidence in the notes of the rationale for the choice of Assessment(s).
33 / Assessments:
· results recorded
· clearly filled in and legible
· complete
· been analysed
· dated
34 / The Assessments results have been fully and appropriately discussed with patient / carer.
35 / There is evidence of informal assessment, and good interpretation of observations to support decision making.
TREATMENT
36 / The aims and objectives of the current treatment are clear ie. Plan and recommendations are stated at end of entry.
37 / The aims/goal and objectives of the current treatment are clearly documented. (i.e; a therapy plan is included)
38 / The future needs of the patient are indicated in plan
39 / Treatment has been discussed with patient / carer
40 / There are progress / up-date reports written
41 / These reports:
§ are timely
§ are clear
§ have been circulated
§ details or a copy are in the notes
§ (If a standard letter has been sent this info has been documented e.g. letter sent, to whom, on what date?)
42 / All inward correspondence been acknowledged in notes
43 / Outcome measures are recorded.
44 / If discharged, a summary in the notes or a report has been written.
45 / Reason for discharge is clear
46 / All notes must be stored in locked filing cabinets
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