Patient Notes

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Hello,

I've recently started treating patients at a local nursing home. After I treated my first patient the nurse in charge asked me 'sign' the patients notes to say I'd treated her. As it turned out she didn't just want it signed she wanted me to fill in notes (as you would do normally for your own records). I did do it last week but I'm not very happy about having filled in notes for them and then doing notes for myself. I don't work for them I'm self employed and don't believe I should be duplicating notes or allowing them to effectively keep my records.

Anyone got any advice??

A

 

You should certainly do it. The situation is similar to a hospital where it is obligatory for all practitioners treating a patient to complete, and sign, the hospital notes.
Just ask the nurse to make a copy for your own records and you have covered all eventualities.

All the best

Bill Liggins

 

Hi I've been in the same position, though I no longer visit nursing homes.
Just make sure the notes duplicate each other exactly then if there is any query at a later date there can be no argument.

 

Hello AKN102,
I would agree with all that has been said.
This system would work in your favour in the event of a complaint. You should record the treatment given and any instructions to staff re the patient's condition on the patient's multidisciplinary sheet (contained within their records). If staff did not comply, and the patient suffered as a result, then you could prove that instructions were indeed given and you were not negligent.
It should be pointed out to the staff member concerned that this extra paperwork imposes an additional cost on you, as it will reduce the time available for treating patients. Therefore, this factor should be reflected in the invoice(s) you submit to the nursing home.
Dido

 

Hello everyone
Thanks so much for your replies. Yes I can totally see all your points as very sensible. My only concern was that of duplication/data protection. I think I need to set up some photocopying arrangement so I write the notes only once and keep a copy for my own records.

Thank you so much for your support it's so nice to be able to post questions here and feel like there's someone out there. Can get very lonely working alone in private practice and I really appreciate all your responses.

Many thanks
Amanda

 

Hi Amanda,

The Residents' Progress Notes are for all Practitoners (GP, Podiatrist, Physio, Optometrist, etc.), to record their interaction with the Patient. The Treatment notes for the residents need to be kept on-site at the facility as part of the Patients' Progress Notes. Every resident has a file, which will be kept permanently either at the Nurses Station or Office. These presence of these notes are assessed as part of the facility's regular Accreditation process.

Writing your notes only in the Progress Notes is all you need to do to satisfy your responsibilities. You do not need to take a copy of those notes back to your clinic, nor do you need to complete a second set 'for yourself'.

Call the Health Insurance Commission if you require clarification, however the above case is the way it must be done in ALL facilities.

Cheers,

Paul

 

Hello Paul & akn102,
Are we talking about the regulation in UK or Australia? If it is UK then the Chiropodist most definitely needs to keep their own records.
Dido

 

Couldn't see a location for akn102, so I've related the case to the Australian model.

May assist others for Australian Nursing Homes...

 

I'm sure it will, thanks, PodAus.
Dido

 

Hello,
I'm actually in the UK so I definately need to keep my own notes. My main concern is duplication and also it's a huge waste of time writing up two sets of notes. My main thinking behind the original question was that although the nursing home have arranged for me to visit I don't work for them I'm basically engaged by each individual client who asks to see me so although if I was for example working in the NHS obviously I'd be obliged to keep notes I wondered really whether I'm breaching confidentiality providing information to the nursing home unless of course i need to give them some specific advice about something. The reason I thought about this is another client at a different nursing home was very annoyed to find out that the Matron in charge had asked me to report back to him after visiting the lady. She took it as a breach of her privacy that she couldn't receive treatment from me without every detail being passed on to the home. Bit of a tricky one because the Home obviously need to be fully aware of our mutual clients wellbeing but on the other hand don't people have a right to privacy??
Amanda

 

Hello Amanda,
If you are am SCP member then I would suggest you contact Kay Blowes the Professional Practice Advisor at the SCP offices. Her contact details are on the inside cover of Podiatry Now. It is always difficult to weigh the patients right to privacy against the need to keep other healthcare professional informed of the patients progress. We do need to abide by the Data Protection Act whilst at the same time being responsible practitioners.
If you are not SCP then your own professional organisation should be able to clarify this for you.
Dido

 

Hi Amanda

In a case of providing information to a third party, you must seek consent from the patient before doing so. If the patient says no, you do not have their consent therefore you do not provide any information to the home. This is difficult if the patient needs support from the nursing staff within the residential home. I think most patients will be understanding of the need to inform but you must still comply with data protection and the need to obtain consent.

Even when writing to the GP or referring a patient on for further treatment, you must seek consent, even if it is only verbal and you must make a note of it in the records before writing the letter.

Common sense does not seem to apply these days. It has been replaced by yards of red tape.

GB

 

Hi GB & Dido,

Thanks yes its the red tape that's a nightmare! It seems whatever you do sometimes you're not doing the right thing for someone. Thanks yes I am a SCP member I'll give them a ring and see what they say about it.

Thanks again to everyone
Amanda

 

hi
i also work in the uk. the homes that i've visited ask me to write in the communication section of the notes the fact that i've visited, but don't want a duplication of my notes, just to know who has been seen by me. if i need the staff to take action afer a visit, then i discuss it with my patient first. hope this helps

 

The nursing homes I visit in Australia now have computer based notes, where I log in & write in the clients progress notes. It is almost impossible to copy this style of documentation, and printing of the clients notes to remove from the property is not allowed. I subsequently use a day sheet where I stick the sterilisation sticker against the clients name from the instrument pack, and a space is left beside this where I can write short notes to take back to my practice for archiving.