For the Record

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!