Podiatry Records/notes

Members do not see these Ads. Sign Up.

Greetings all,

I have been trawling the net to no avail - there does not seem to be any published research, standards or even examples of how and why Podiatrists record patient data, in particular progress notes.

At the moment we are reviewing our record procedures (at a University teaching clinic), with the view to having 'best practice' standards in documentation and from a teaching and learning point of view.

We use a modified Problem Oriented Medical Record System, with progress notes recorded in the S.O.A.P.E format. Currently we are converting E from 'education' to 'evaluation' to implement a goal oriented approach (setting measurable objectives from the treatment plan).

So - what is everyone else doing? I know that many hospital and institutional practices follow the protocols for general record management, but how do they record progress notes? And our friends in Private Practice - to what degree is there idiosyncratic variation from practice to practice?

I eagerly await your feedback, and anything you can point me towards in the way of publications.

cheers,

Felicity

 

Hi there Felicity,

I work in private practice within a physiotherapy clinic where physio and podiatry is kept in separate sections within the same folder. With regard to podiatry documentation, we use the basic order of the SOAP notes but with some modifications, where we include:

(S) Chief complaint and patient's subjective description of symptoms,
History - duration, previous injury, triggers, relieving factors, previous treatment, investigations eg. X-ray, ultrasound,
Activity levels and footwear types used,
(O) Objective assessment - vascular, neurological, dermatological, biomechanical, weightbearing/gait description,
(A) Differential diagnoses,
(P) Treatment - short term, long term, patient education, steriliser details (if instruments used).

We generally send a letter through to the patients GP after the first review and this is kept in the patients chart, this also acts as a quick summary for the physios if they are treating the same patient. We also store orthotic prescription forms, GP referral letters and test results.

I am currently working on putting together a Procedures Manual for the practice, and like yourself, am finding it difficult to find specific standards for podiatry practice through APodC. I have been sent a copy of a Procedures Manual for a Hospital which has helped greatly as I have been able to use this as a guide. I am gradually putting together the sections, inlcuding a glossary for podiatry terms used so that the physios can decipher our abbreviations.

With regard to documentation variations between practices, I have noticed differences within the private sector (with previous employer), mainly with regard to layout (and comprehensiveness) , and wonder if these variations are due to differences in the podiatry course over the years ie. present day compared with 20 years ago. When I was at uni (I finished in 2002) it was was always drummed in that "if it isn't charted, it was never said" and have taken the approach of always having each piece of information recorded on paper.

I'd be curious to know if the Podiatry Clinical Standards are due for review soon, as I have found the new Infection Control Standards to be much easier to understand and implement into the Infection section of the procedures manual.

I don't know if this has been useful, but there you go...

Regards

Donna

 

Thanks Donna, that is tremendously useful. It is great that you are putting together a procedures manual. With the introduction of Podiatry Assistants into our profession, I think it is really important that we have some strong and clear guidelines for documentation - they are dependant on our care plans for their work.

You are right about how things have changed over the years. In the more litigious environment in which we work today, I think our records are our insurance!

Thanks for your help Donna.

cheers,

Felicity

 

Hi Felicity

Not sure I can add much to what has been said except:

1. Physiotherapists certainly challenged my level of note writing many years ago. I certainly took in all I heard but the physios got me documenting a great deal more than I used to.

2. From the medico -legal viewpiont (I do this from time to time) nothing infuriates me more than abreviations and short hand (also guilty ). Trawling through someones notes and having to decipher their abbreviations just to begin to understand what they are saying can leave them open to misinterpretation.

Do we have a standardised approach, can this be international in application or, do we ban medical shorthand altogether. Part of me wants some abreviations as this is simpler to write.

When it comes to sports podiatry do we consider using diagrams as are used by physios and osteos?

Interesting post.

Thanks
Ian

 

In all of the Community Health Centres I've worked at (4+) a modified SOAP format has been used.
S - Subjective - quote patient.
O - objective - what you see.
A - Actions (treatment) or Assessment depending on the Pod.
P - Plan - return period, referrals, education given or required, future treatment requirements etc. May or may not include treatment depending on how the Pod views "A".

All patients have a neurovascular Ax & medical Hx update annually and plans are changed accordingly. We have separate NVAx & biomech forms which are dated and included in the file. Copies of GP letters which result from the Ax are signed & attached.

We have a set list of abbreviations - standard Pod ones, but the list can be referred to if you're unclear what something means.



Our files are quite detailed, and whilst probably not perfect, they're a long way from "B/F nails & op. Post.op hib.clens"


Re.use of shorthand and abbreviations, I think they're ok as long as they're consistent throughout a profession - if 9/10 like-practitioners know what it says I think it's accepted as normal. I wouldn't expect an electrician to read and understand my files any more than I'd understand their wiring diagram thingies.

 

Our files are quite detailed, and whilst probably not perfect, they're a long way from "B/F nails & op. Post.op hib.clens

Wow! That dates you to Abbotsford days I suspect (damn these pseudonyms....)

 

Hi Felicity

The SOAPE model and POMR are effectively one of the same and were devised by the same author (Weed) back in the sixties. He intended the Assessment part of the SOAPE model to incorporate a POMR approach. SOAPE was quickly adopted by nursing and later other allied health professions and modified to operate as a passive record system only. At the time POMR was thought too time consuming to be universal and so pragmatism prevailed and SOAPE minus POMR, was more common. A lot of water has passed under the bridge since then. Podiatry was late in picking up SOAPE and has not always kept itself up to date with data collection. So I see two things emerge SOAPE with POMR are good teaching tools and kepinfg as teaching models but dat collection systems and care models have moved on considerably.

The consensus appears to support the belief that both systems are simple to use. POMR tends to be more disease orientated, diagnosis specific, and treatment centred. It takes the complete patient into account, definitely provides a pro-active approach to care, prompting the practitioner to identify the clinical problems, before prioritising care plans. Majority of practitioners who use the POMR system find it helpful in their place of work and POMR approach has been adopted throughout the caring industry because it is compatible with accountability and can be programmed into electronic databases. That said both systems are actually passé now. From a base line perspective however SOAP is better than nothing and other variations such as Bradshaw¹s ADTAR (assessment, diagnosis, treatment, advice and referral) have also found application in podiatry. Whilst both systems encourage better recording of narrative data they are passive and concentrate on diagnosis to the detriment of active problem solving and clinical decision-making.

In training centres (UK and Australasia, certainly) our record keeping systems are designed to match the syllabus and subsequently patient data collection forms rarely follow a systematic data collection logic. Because the training formats are then replicated in practice there is history and practice which is in need of complete overhaul if we are to match ‘gold standard’, as practiced by other disciplines.

Brief history of data collection in podiatric education (Commonwealth) indicates SOAP model was universally adopted into school’s syllabuses round about the early eighties a decade and a half after it was first introduced to nursing. The E, which stands for Evaluation (of care plan), was ignored and only SOAP was used as a working model. The most reasonable justification for ignoring evaluation probably relates to schools with a standing population of frequent flyer patients who never “graduate”, or as Seinfeld would say. “Same old, same old (treatment). As you know some centres took on the E, as education, but within the original model this would have been covered in the Plan.

Come the time and place of degree education meant we could as educators start the education of podiatrist as clinical scientists by using the SOAP approach and relating this specifically to the scientific method. So Subjective & Objective data collection became information gathering, Assessment could be used as working diagnosis (hypothesis generation) and Plan would represent hypothesis testing. This meant that Evaluation became a natural addition which unfortunately most centres ignored. Continued absence of E probably related to the common practice of allocating patient loads to students dependant upon their perceived levels of seniority. A flaw in this system is students graduate to the next level but their patients stay at the same level of care. Systematized evaluation of patient’s case programs did not automatically take place and would happen only by serendipity. A gross omission in the preparation of professions, not to mention care of clients, I am sure you would agree. But hey we are not perfect.

As the microcomputer impacted on the health care industry the need to collect data drove major initiatives and the POMR system was revalued by those responsible for governance as a very important method because it directed clinicians to specific care plans which were pathology and discipline sensitive. Schools of podiatry adopted POMR not for this reason but instead because it gave structure to clinical problem solving and making clinical judgments. So we reflected a global trend without realising perhaps the reasons why this systematised approach had become imperative.

By the end of the century the major health care disciplines were encouraged to embrace detailed care plans and clinical pathways so as to inter-relate better with each other in the pluralistic management of clients receiving primary and secondary care. This did not include podiatry as a whole (because we are on the fringe). Now there are some obvious examples around which show commitment to the new order but these are still in the minority and most practitioners continue to use SOAP completely oblivious to the bigger picture.

The psycho-social model of care has given greater awareness to the importance of patient motivation and now systems of negotiated care are far more prevalent today. Flinders University for example has developed new approaches which engage and empower clients to take greater responsibility for their illness. The revolutionary approach changes the emphasis from the traditional medical model of practitioner dependency to a physician who is a health facilitator able to empower clients and support self care. If the politics of health are moving away from the medical model then it is timely to reconsider podiatry clinical curriculum. I am not sure in my own mind whether podiatry as a profession is aware of this drift and fear we may as a discipline become more marginalized because we are not keeping abreast of major changes within the health care industry.

But hey what do I know?

Cameron

 

Phew! Thanks Cameron - completely on the ball as usual. I agree with your thoughts and sentiments. I particularly feel that the POMR approach does tend to reduce patients to a series of problems which need to be solved. With many of our patients 'failing to graduate', they are then classified as recalcitrant, and records start to show hideous statements such as "Just nails as usual".

Podiatry started way back (when you and I were roaming the Jurassic Jungle of education) as quite a care-oriented profession. As we moved into the 'big league' of Universities and hospitals, we adopted a more cure-oriented approach, more typical of the medical model. The POMR system is well suited to this, and at least by using this more detailed narrative form of progress notes we cast aside the "B/F Nails & op" legacy which was not only uninformative, but a legal minefield. OK, so we never really swallowed the whole POMR system, but SOAP(E) was a demmed useful way to make students really consider and spell out what happened in the concultation.

My worry is that, as you cogently state, POMR/SOAPE is SO yesterday. I cannot find any recent literature about it. It is still used in our teaching facility - to varying standards and levels of success - but is it where we are going as a profession?

The negotiated care plan is great in theory, and can be incorporated into the SOAPE (especially in the E "evaluation" section, where the practitioner can record the consensus care objectives reached with the patient). My concern is that we as a profession do not have benchmarks for patient records (in particular the progress notes). Without these our risk management strategies, from a professional liability standpoint, are non-existent.

So, be a pet and write some gold-standard benchmarks for me. I promise to use them! You've got the knowledge son, just let it out.

cheers and L&K

Felicity

 

Too kind Felicity but I dare say you will surpass anything I could do. Working on a new project just now which relates to Chronic disease managment and patient empowerment. The pieces are still coming together but will bare in mind all you have said and keep you posted if anything turns up.

Missing you already

Cameron

 

That it does!!

Abbotsford's "Sunset Years" though. (Don't want to age myself any more than nature is!!)

 

Interested in others people opinions on electronic records. We have been using an electronic patient records for 18 months and found this too be a great advantage once typing skills had improved. There are many timesaving features with far less use of abreviations. We also cut and paste from notes into referal letters / reports particularly if you are taking comprehensive notes.
The use of note templates in the SOAP format are also extremely useful.

Andrew v E

 

Andrew,

Last Friday I attended a NAHCC meeting with other representatives from AH disciplines and with some Gov beuracrats from Health Connect and NEHTA.
The federal and state governments are contributing large amounts of money to establish a safe/secure electronic health record that will follow the patient and have the necessary health information available to all of that patients health care providers (that the patient wants).

The future will see a single patient identifier as well as a single HP identifier. the record will be linked into pharmacies so medication checks will be automatic, relavent path and imaging info will be readily available etc.

A recent trial was conducted in Kalgoorlie WA, that has been recieved very favorably.

There is still work to be done on common language, using Snomed that is being adapted for Australia. And a National Catalouge of Medicines has been collated, with standard names for all including herbal, chinese etc.

The above websites have lots more information, and the whole project will come about through an osmosis rather than a big bang, with high bandwidth connectivity needed for many of the features of e-health

 

Very interesting developments and at a conference on chronic disease management in Perth on Thursday there was a hint of something like this coming. Professor Branko Celler (University of NSW) outlined developments in remote monitoring technology which could only exist if there was a national database as you describe.

Cheers
Cameron

 

Stephen,
My work in the public system, where electronic record whould have to have the greatest potential for improving communication amoungst the large numbers of health professionals providing services to the same patient, is the RGH Hospital as a podiatric surgeon. In theatre we do all our op reports, dischage summaries and discharge medication with electronic records via a terminal in theatre. All the codeing, follow up appointments etc are all done very simply. Outpatients we still use paper record.

In the private system a lot of our medical imaging reports and pathology reports are all e mailed and atached then to the patients file. Let the technology roll on! Computers are now so much cheaper, faster and reliable. Networking and highspped broad band commonplace.

Andrew

 

Hi Andrew

Good news indeed. One of the main problems with electronic data has been maintaining patient confidentiality however as systems are being developed then this hazard seems to be overcomable. The trend towards care pathways and shared care plans will be complement by an electronic data base and eventually forge adaption across the board.

Brave new world ahead.

Cheers
Cameron

 

Dear Stephen,

Many thanks for the information re the introduction of SNOMED, and for the links (crikey was a set of acronyms, I'm glad you were able to make it to the right meeting). I visited the SNOMED site, and you have to hand it to them, they are able to create a huge website without once giving away any actual details of the language/coding product.

I agree that we will all be moving towards the use of electronic health records. It was very interesting working with the Podiatry Assistants Course, as many of the private practices in Victoria seem to be moving in that direction (with some teething problems).

I am not sure when it will hit the education system, but I do believe that we need to be foreshadowing the event by getting our students at least competent in using appropriate record keeping techniques (electronic or otherwise).

cheers,

Felicity

 

Felicity

Have you had a chat with Andrew Schox <schox@swiftdsl.com.au > He is a podiatrist and computer programmer and wrote the CUPiD (Curtin University interactive database). We used it for eight or so years and Andy got it to a fourth generation which he has subsequently developed for private practice. He began developing the system as a student <http://podiatry.curtin.edu.au/encyclopedia/demographic/> and has supervised other undergrads subsequently who have taken the evaluation of the database system, further. Adnrew is very approachable and am sure he would welcome enquiry.

Cheers
Cameron

 

Hi Felicity
Feel a bit out of my depth here. All i can add to your discussion about note-taking is that in my uni ( i am a student) we use a similar version to SOAP but we call it ATAC
Assessment
Treatment
Action
Collaboration

however on placement with the NHS hospitals we use the SOAP method

Not much help but at least i have made my first imput

 

Kath:Welcome to the club!As for charting here in the USA,we use SOAP.That being said,there are also preprinted forms where all you have to do is circle and or check off boxes.

 

Snowmed

Felicity,

the Australian and other governments are in final discussions with the "SNOWMED People" re licencing of the product. Once licenced it will be freely available to all Australian health professionals.

Cameron,

The patient confidentiality is on of the big issues Health Connect is dealing with. while a patient may be happy for their podiatrist to be aware of their medication history, they may not want some of the discussions that they had re mental health issues with their psychologist widely available, and the more control that is given over a health record the harder it is to manage etc.

It is thought that people with bigger privacy concerns will opt out of the eHealth record.

 

Thanks Stephen.

Apparently there are many patients in Australian who have several GPs, preferring one not to know what drugs they are receiving form others.

Chris Kirtley and I were interested about a decade ago in applying for a grant to track nomadic A&TSI populations on walkabout using telemedicine. Our intention was to use their GPs as the centre point and monitor their progress using centres of excellence with relayed images. Our grant was not approved (due to a podiatrist objection) although the project was highly regarded. Quietly we were told telmedicine would become a medical specialty. Certainly one of the problems which did challenge the initiative was confidentiality. So it is good to see progress has taken place on several front.

Cheers
Cameron

 

Felicity,

We have similar SOAP problems. It is further complicated by slightly different discussions on how to SOAP between Neale's and Turner & Merriman.

When we built our clinic we very carefully made sure all our consult rooms were wired to enable us eventually to move to a computerised records system (when we could afford it) - Technology has since moved on and I now dream of a wireless network with portable devices.

Could I suggest you speak to Sara at UniSA? I have had some discussions with her in this area.

regards

Harri

 

Thanks to all for the very interesting contributions - it has been of great assistance. And thanks Harriet, I will follow up with Sara. Hmmm, perhaps the time is looming for all us APEs (Australasian Podiatric Educators) to get together for a spot of mutual community grooming and flea sharing (OK, perhaps not, but some information sharing could be quite good).

I confess that I am only newly returned to full time Pod Educating, after a 10 year hiatus of Marketing, Health education, and Primary and Secondary teaching (and an intensive breeding program). What struck me was that Podiatry has progressed in leaps and bounds in so many areas of our practice, and even paradigm. But our documentation is sadly lagging far behind.

cheers

Felicity

 

Here is my little bit, Im in the same boat as Kath H also a student (1styr) we use the same ATAC model, I can only summise at the same uni? I am finding that the use of podiatry abbreviations is not sitting we with me, I currently have 13 yr experience within the NHS in several clinical roles and we are activley discurraged from using abbreviations for medico/legal reasons. However, in uni we are actively encourraged to use them. I feel an argument comming on.......
They are educating use to be thinking practitioners (shepards not sheep)

What thoughts does anyone else have on this matter?

currently a frustrated toepicker.............