Record Keeping - Your Guide to Accurate and Effective Patient Information

Module: Record Keeping - Your Guide to Accurate and Effective Patient Information

In this module, you will learn the art of gathering and documenting critical information from your clients and patients to create accurate and informative records that can be used for further referrals to other healthcare professionals. We use the well-known SOAP model and the recognized ICF form for collecting information from patients. This will give you a solid foundation for preparing a structured report that helps you assess prognosis and determine further treatment courses for your patients.

Learning objectives:

Understanding the importance of record keeping:

• Understand the importance of accurate record keeping and how it impacts patient care, communication with other healthcare professionals, and insurance and legal aspects.

Master the SOAP model:

•    Subjective: Incorporate techniques for listening to and documenting the patient’s subjective information, including medical history, pain description, and functional status.
•    Objective: Learn to conduct a systematic objective assessment using tests, measurements, and observations.
•    Assessment: Develop skills to analyze and summarize information to make an accurate assessment and differential diagnosis.
•    Plan: Design an effective treatment plan that includes short-term and long-term goals, treatment methods, and follow-up strategies.

Using the ICF (International Classification of Functioning, Disability, and Health) schema:

• Understand the structure and use of the ICF schema to categorize and document the patient’s functional status, disability, and health.
• Learn how to obtain information that covers all aspects of the patient’s functional ability, including body functions and structures, activity level and participation, and environmental and personal factors.

Journaling techniques:

• Develop skills to structure medical records so that they are clear, concise, and meet documentation requirements for both internal use and referral to other healthcare professionals.
• Learn principles for writing professional, well-organized reports that can be easily understood by other healthcare professionals.

Ethical and legal record keeping:

• Understand the ethical and legal aspects of record keeping, including patient confidentiality, data protection laws (GDPR), and regulatory requirements.
• Identify common record keeping pitfalls and develop strategies to avoid them.

Practical training in record keeping:

•    Participate in realistic case studies where you will have the opportunity to practice collecting patient information and writing records using the SOAP and ICF models.
•    Receive guidance and feedback from experienced instructors to improve your recordkeeping skills.
•    In this module, you will develop a deep understanding of how to effectively collect and document patient information. This will enable you to create comprehensive reports that not only provide valuable insight into the patient’s condition and treatment plan, but also improve communication with other healthcare professionals.
•    You will be able to write records that support further referral, research and ensure continuity of patient care.

Let this module be your first step towards becoming a competent and skilled therapist who sets the standard in recordkeeping.
Enroll now, and take the step towards mastering the art of recordkeeping!