Documentation Standards

The local criteria are in accordance with College of Occupational Therapy standards.

• Patient Registration

       All inpatient data to be registered on the CMS computer system by completing     the patient registration form no later than one working day following the initial contact.

1. Assessment
2. Writing will be legible.
3. Writing will be in permanent black ink.
4. The assessment will be clearly dated with day, month and year.
5. The assessment will be documented to include subjective information and findings of the objective examination.
6. All relevant negative assessment findings will be recorded.
7. All relevant past medical history will be recorded in the initial assessment information.
8. All assessments will have a full signature and printed name.
9. An initial treatment plan will be clearly documented.
10. Goals
11. Individual patient goals will be set and dated, relating to the treatment plan.
12. Goals will be reviewed and recorded in accordance with relevant specialty guidelines.

• Description of Care Episode

1. Notes will be related to the problem/goal list by the recording of appropriate number.
2. At least the first entry in the notes will have a full signature, printed name and designation  The Occupational Therapist  full signature will be written on each sheet of the treatment records.
3. Any subsequent changes in clinician will have a full signature and printed name.
4. All entries will be recorded within one working day.
5. All attendances/patient contacts/patient related contacts will be dated and initialled.
6. Judgemental statements of a personal nature will not be included.
7. Progress notes will include reference to any education and advice given to the patient.
8. A record of a home assessment visit and summary of findings will be retained in the treatment records where applicable, along with a list of who the report was sent to.
9. Loaned equipment issued to the patient will be recorded.
10. Notes should be continuous, when possible.
11. No abbreviations must be used.

• Corrections

1. Corrections to the notes will be scored across with one single line and initialled.
2. Correction fluid will not be used.

• Students

1. Student notes will have full signature and printed name of the supervising clinician recorded at the end of the initial assessment.
2. If the supervising clinician changes, the full signature and printed name of the new supervisor will be recorded in the treatment records.

• Patient Consent

1. All relevant discussions and a complete consent procedure will be recorded in the treatment records (where applicable) in accordance with the Directorate Consenting Policy.
2. It shall be clearly documented if a patient declines treatment.

• Home Assessment

1. Reports of home assessments will be produced in the agreed format within one working day of the assessment.
2. Staff should make every effort to file the report into the patient's medical notes within two working days of assessment.

• Discharge Summary

1. A discharge summary will be recorded for all patients.
2. The discharge date will be recorded and signed.
3. For all outpatients a discharge letter will be forwarded to the GP or Consultant and a copy retained in the records.
4. The discharge letter will be written in an agreed format.
5. The number of contacts per clinician and input values will be recorded per month on the front sheet.
6. Any change of clinician will be recorded on the front sheet including the date and number of contacts.
7. A discharge date and discharge destination will be recorded on the front sheet.

• Removal of Records

1. Community staff undertaking outreach visits or sessions may take records home overnight if they are not returning to base. The records must be limited to those required for a particular GP session or visit.
2. Staff will ensure that records are stored securely at home - records must not be left unattended in a vehicle.
3. The staff member will return the records to base on the first subsequent visit.
4. In other circumstances patient records must not be removed from the relevant hospital/school site without the written agreement of the Occupational Therapy Manager.
5. If staff are given authority to remove records for a particular purpose the manager will retain a list of the patient's names, the total number of records involved and the expected date of the return.
6. The staff member will report to the manager on the planned date of return and check the records in against the manager's list.
7. Retention of Records
8. Treatment records are maintained for a minimum of 7 years after the conclusion of treatment.
9. Obstetric records are held for 25 years.
10. Records relating to children and young people are kept until the patients 25th birthday or 8 years after the last entry if longer.
11. Records will be stored securely at all times.
12. Computerised occupational therapy records are registered under the Data Protection Act 1984.
13. Records will be released with the patient's written permission.
14. A procedure is in place for patients to access their post November 1991 records.
15. Compliance with Documentation Standards
16. Adherence to the standards will be monitored through documentation audits, individual clinician reports generated by the CMS and through the supervision/IPR process.
17. Any staff member experiencing difficulty meeting the standards should seek advice from their line manager of the Occupational Therapy Services Manager. The manager will adopt a supportive role by discussing the situation and agreeing an action plan which will address the relevant issues.
18. Individual members of staff are responsible for ensuring that documentation meets professional standards at all times.
19. Failure to comply with the standards may result in disciplinary action.