Recording professional advice and keeping case records
Alison Hodson explains what you need to know when dealing with registered patients or talking to non-patient groups
All SLTs should be aware of the importance of accurate record keeping. It is a requirement of employers, the profession and the Health Professions Council (HPC), and may be required in court in cases of litigation or tribunal.
Flow chart: guidance on record keeping
Advice to prevent speech, language and communication difficulties
Accurate case records are also our only sure defence if a complaint is made against us. Maintenance of records is a core responsibility, whether we work in health, education, independently or in the voluntary sector.
General advice on speech, language, play, listening and attention, information skills
Not a patient
Speech, language, communication problem suspected
Consent sought/obtained for assessment
A quarter of HPC complaints actioned from April to November 2005 had inadequate recordkeeping as part or all of the complaint. This underlines the importance of the task.
The guidelines for record keeping are outlined in Communicating Quality 2, and will be updated in CQ3. Our records need to be factual, accurate, objective, contemporaneous (written within 24 hours), dated and timed. They should record all patient activity whether direct or indirect. This includes discussion and telephone calls, with a clear record of what was said and action agreed.
This is straightforward where a patient is clearly identified for treatment. However, our work is constantly changing, and in the light of new health promotion initiatives we are dealing with more cases where we are giving general advice to groups with no identified patient or client at the centre. In these cases, we are not required to record advice given, but this leads to less protection for both therapist and individuals receiving the advice.
The RCSLT Professional Development Board has issued advice to cover the situation. This can be found in Michelle Morris’s paper, Accountability for Professional Advice Given to People who are Not Registered Patients – available on the RCSLT website. This advice relates only to communication. Any advice on dysphagia management should always be recorded in an independent patient record. The advice applies to all staff working
No recorded contact activity specific to patient but record general advice, eg male approx 60 yrs and statement of advice given
Support individual and/or family to understand importance of consenting to treatment (may take some time)
Peer reviewed every four months
Follow path for treatment
in a speech and language therapy department, including SLTs, assistants, technical instructors and co-workers.
Foundation principles for preventative advice The advice must be based on general awareness-raising strategies to facilitate communication development. It cannot be targeted at specific individuals or based on a skills profile generated from assessment.
Advice should be evidence- or consensus- based, ie it should either be attributable to research or generally accepted practice.
If more advice is required, then you must gain consent and open a patient record. If the family is reluctant to do this, you should advise them about what consent and becoming a patient would involve. It does not free the therapist to give more specific advice without registration.
Consent obtained for treatment
Accountability Clinical teams could develop a standard presentation or set of key evidence-based statements to structure presentations. These could be paired with a set of responses to frequently asked questions. The local clinical governance committee should approve this package.
There should be an anonymous set of notes containing basic details about the function. Peers should audit these every four months to monitor adherence to guidance and appropriacy of advice.
For a more detailed explanation visit: www.rcslt.org/resources/publications/ downloadable
Alison Hodson On behalf of the RCSLT Professional Development Board
bulletin April 2006