In this guide you will find a simple to follow set of best practices in recording clinical notes for your practice. However you record your notes you will find some ideas and approaches here which should improve them, providing better outcomes for your patients and lowering the risks to your practice.
Why record clinical notes?
Our experience shows three key benefits to your practice for recording detailed and accurate clinical notes.
Better patient outcomes and continuity of care
Patient wellbeing is the reason you are in Allied Health. Understanding each patients history is key to providing effective individualised treatment. The only sure way to provide continuity of care, and ultimately a better outcome for you patient, is to record detailed and accurate notes of every consultation.
AHPRA and the Individual National Boards know this which is why they publish guidelines on effective clinical record taking.
No matter how good your memory, it simply isn't possible to remember how you've treated each patient in every consultation. And you can't rely on patients to remember this clinical information. If a patient doesn't come to see you for a period of a few months, you need to know that you can look at those records and be sure you know how and why you treated them all those months ago.
Clear evidence of your treatments
Your focus is always on your patients well-being and resolving their health goals. The last thing you want is to have your valuable time taken away pulling together notes from your memory when you have a question or a complaint from one of them about the treatment you have provided.
Accurate clinical notes provide clear evidence of what you did and why you did it for every consultation. If you keep your notes well organised then gethering those notes to field questions and defend against complaints will be an easy task. Your time can be spent focused on your patients instead.
And when your professional reputation is on the line and your practice at risk as a result of a complaint against you, then having clearly recorded clinical notes will be your best defence. For a little regular effort you will massively lower your risk if something goes wrong.
It's just not worth leaving yourself exposed by not recording notes.
Protection against insurance provider requests and documentation audits
You've heard the stories, Health Insurers are becoming more aggressive around auditing their payments to Allied Health professionals and the quality of note taking is a clear target. Health insurance agreements generally require you to provide your notes on request for any patient that is claiming for your services.
In Australia, there have been a number of cases where Health Insurers have involved AHPRA with claims of poor record keeping. At best this has resulted in a requirement to undertake training and further education on record keeping requirements. At worst the Health Insurers have threatened to reclaim insurance payments from the Allied Health professionals involved.
Complaints from patients to AHPRA have also resulted in training and further education requirements for individual health professionals. It's wasted time and effort for you which you could spend on helping your patients, growing your practice, or spending time with friends and family.
The simple facts of compliant note taking.
As an Allied Health professional taking compliant notes is a simple concept. You just need to:
- Record a note for every patient consultation
- Make sure you record all the right details
- Never lose a note that you have taken
- Ensure that every practitioner in your practice does the same
- Do all this while maintaining patient privacy and data security
Of course, it’s just not that easy in practice. There are challenges at every step.
A note for every consultation
This one is super simple, but every patient consultation requires a note to be recorded. The type of consultation will change the information that you need to record (see below).
However you take your notes you should be putting in place some way of tracking when you miss a note.
Notes are possibly the least interesting part of running your practice. There’s always something more important to do and it’s really easy to let consultations go by without recording a note for them. No matter how good your memory, with the volume of patients you will be seeing there’s no way that you can remember each note you’ve missed without a system that keeps on top of it.
The last thing you need when a patient walks into your treatment room is to realise that you missed their last note and you can't quite remember what you did. Or even worse, it's clear that notes are missing when you respond to an audit of your note taking process.
Recording the right details
Once you are taking notes every for every consultation you need to make sure you are recording the right detail. There's no value a note with hardly anything in it. Likewise, if you record too much information, or do it long hand, you are wasting time you could be spending with patients or on building your practice.
We have a clear perspective that there are two general types of notes that you record during a patient consultation, initials/reviews which record more detail and treatments which record less.
Initial consultations and reviews book end your treatments
Initials consultations and reviews are similar to a patient visiting a GP where a particular presenting complaint is discussed. Detail of the complaint is recorded, the necessary tests and observations are performed and a working diagnosis is detailed. Then a treatment plan is put in place, which for the GP example could be a treatment of medicine. There is often a follow up review to discuss progress and update the treatment plan if required.
It is no different for Allied Health. The initial consultation records many of the same details, presenting complaints, tests, assessment/diagnosis and a treatment plan. All of these elements should be well documented so that when it comes time to review patient progress it is clear what progress has been made and how ongoing treatments need to be adjusted.
The treatment plan should note the frequency of treatments and when the next review is planned.
Reviews then record substantially the same information, updated to reflect the progress since the initial consultation or the most recent review. Subjective details of the complaints should be updated based on patient details. Tests should be re-done and the updated results recorded and an update to the working assessment/diagnosis should be added to the note.
An update to the treatment plan can be made at the review based on the new working diagnosis and how the patient has responded to the intervening treatments.
Treatment consultations are the equivalent of medicine
Treatment consultations are where there is a substantial divergence from GP's. Each treatment is a return consultation for the patient where they will be present in your practice. The details of the initial consultation or any reviews should be available to check and update if necessary but the primary note taking requirement is a record of the treatment itself.
With regular consultations your working diagnosis can be updated more frequently as a patient responds to your treatments, and the forward treatment plan can be adjusted as necessary.
The primary focus will be recording the details of the treatments you have performed directly, depending on your particular Allied Health profession, as you deal with a patients particular presenting complaints.
You want all patient details in the one place
There's no point in having your clinical notes in one place, any file attachments in another and any other general notes somehwere else. Having all the notes for you patient in one place and easy to access and review is important for you to keep your treatments on track and encouraging you to keep your notes up to date.
It's also important to keep your patient file focused on what you need to treat your patients. Having invoices, payments, recalls and other administrative details mixed in with you patient file will distract you from the important focus you need during a treatment.
So make sure you keep all the critical files you need for your patient wellbeaing together in one place, while keeping out all the potential distractions.
Legibility and understanding are a top priority
Note taking guidelines have clear requirements that your notes are legible and easy to understand. They need to be of a quality that, in the case you were unavailable, an alternative practitioner could step in to treat your patients with confidence by just reading their patient file.
Legibility doesn't just mean that your handwriting can be understood, all the special codes and short hand you use during your note taking must have clear and unambiguous meanings. There needs to be a key and descriptions for every short hand code that you use.
Never lose a note
It goes without saying that once you record a note you should never lose it.
If you are using paper then protecting that paper is of ultimate importance. The simple act of filing becomes very important as placing a record in the wrong place will lead to lengthy search for missing documents. And that's only one of the ways that paper is a poor choice for clinical note taking, privacy is more difficult to achieve and there are just too many ways that your notes could go missing.
If you are using a digital system, then the appropriate encryption, privacy and backups should be in place to make sure that no matter what happens every note you record is always available.
You are responsible for your practice
If you have associates at your practice, or you have multiple locations, then you need to multiply these requriements accordingly. The full note taking detail needs to be recorded for every practitioner consultation across your entire practice. AHPRA and the Health Insurers will hold you responsible for the workings of your entire practice.
With multiple practitioners legibility becomes even more important. There is a much higher chance that you will have patients see more than one practitioner and making sure that everyone understands notes recorded by other practitioners is necessary to ensure positive patient outcomes.
Privacy and security are increasing in importance
The USA has HIPPA requirements, Europe has the GPDR and Australia has it's own set of privacy principles. Medical data is particularly sensitive and often has additional privacy and security requirements in place.
Keeping your patient's private details secure is an important consideration for your clinical note taking. Whether you are taking paper notes, using a paperless desktop application or an online cloud service there are risks which should be reviewed and understood.
For paper records, where are the records held? Who has access to them? What controls are in place to check them out to practitioners and make sure they are returned? Are backups in place in case of fire or theft?
For desktop applications, is the PC adequately protected from viruses and malware? Are backups in place in case of fire, theft or hardware failure? Where are the backups held and who has access to them? Are the backups tested regularly to make sure they can be restored? How long would it take to get access to notes in the case the PC is no longer available? Who has access to the application itself? Can you control who sees the notes?
For online applications, do they have the necessary security and encryption in place? Where is the data held and does that place have the necessary privacy and security requirements? Are backups in place, and how often are they run? Are backups tested by running regular restore of the data? Who at the service provider has access to the notes you record?
And there are more in each case given the complexity of privacy and security that needs to be considered.
Getting compliant clinical note taking right
There’s a whole lot of focus required to get clinical note taking right, particularly if you decide to do it yourself. This article provides a high level outline but if you want to take compliant notes you need to drill down into each area and really understand the core requriements and all the edge cases that you ruin your compliance process.
Or you could try out Instinctive Notes. It was designed from the ground up to support compliant clinical note taking out of the box. If you are committed to better patient outcomes and protecting your practice and your reputation from risk then it's worth taking our 30 day free trial today.