A friend of mine recently raised a good question: What is
the standard for record- keeping when it
comes to treatments? I know we officially learnt this at some point in time. I think my
personal style of note taking and record keeping has definitely evolved with
experience in various settings. I do know that this was something I really
struggled with at varsity in our clinic practicals. It may not seem like it to
those who know me but I have a slightly perfectionistic nature in that I hate
getting something wrong, and if I do something I make sure I do it right the
first time. This fear of being wrong really tripped me up when it came to
writing notes in hospital folders. I found myself pouring over what others had
written and how they had written it, then I’d rehearse what I was going to
write. It was a process of editing and re-editing it until I felt vaguely
confident in what I was going to say. This fear became problematic because I didn’t have a lot of
time to write, and when I eventually made myself do it, I had forgotten half of
what I wanted to record. The SOAP (Subjective, Objective, Assessment and Plan) notes format
helped a lot but we were never really taught this formally. So here
is a link on how to do the SOAP note thing properly.
In my clinical setting now (working in private practice) I
tend to use a blank note page for each client. Each client has their own folder
which is safely locked away in a cabinet in the office. Reports and accounts
are password protected on my computer. The structure of my progress notes changes according to each patient and I use my own shorthand when recording progress. I have looked around and
there are many places which provide useful templates to use when one wants to
keep track of progress. Speakingofspeech.com has a whole list of various data
forms that you can find here. There are also several apps (Android and Apple) that can be used for note taking (this topic calls for its own separate post!) In South Africa we don’t need to submit IEP (individualised education programme)
goals for each and every child but it is important to keep record of measurable aims and outcomes.
These forms give a nice structure for doing so.
Official guidelines on record keeping in private practice
are hard to come by, but what I have found in terms of legislature (and what I
have gleaned from more experienced practitioners than myself) is the following:
- Keep record of everything!
- Keep your records for 5 years (and then a little bit longer just in case)
- Keep it confidential (unless you have written permission from the patient to share it)
- Another professional may have the info if they have a direct interest in the case
- If you email anything you should make it uneditable (PDF it) and password protect it. To do this click on Save As from the File tab in word, change the file type to a PDF and then click on the options tab. Check the box that says Encrypt the document with a password. voila! Make sure the person you are sending it to knows the password.
If you have any other information on this topic that you
think is important or new information I’m not aware of please share it here!
