Domicillary note taking

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Hey,
How does note taking work when on nursing home "home visits" for a lone private practioner? Notes will be a must but do I both write my own and on a care plan for the patient? Or could I write my own and send as a secure file back to the nursing home ? Whats best practise?

I am sorry if this is an issue that has been rised before or just requires burning more midnight oil on data legistation acts!

Hannah

 

Hello Hannah,
My practice is 50% Doms: I make notes in my Filofax and type them into Podware4 on my Laptop as soon as I can. Collegues use old style carded notes and write them as they go along. It doesn't really matter which system you use as long as you log it as soon as possible. I am looking into using a tablet PC and emailing my main PC from site. Most of the nursing homes I've visited just log that you have attended, they won't let you near their care notes. You can email them with details later but I doubt they'll do anything about it.Dont worry about care plans~ they won't take any notice of anything "The Chiropodist" says ( you won't have a name) sorry to sound so cynical, but I've been at this game for 20 odd years, and sadly this is the what the real world is like. My main advice is always write treatment down as soon as possible, and log ANYTHING significant that you notice in a separate file. If the home is investigated ( and they are a lot, these days) you may be asked why you didn't report certain things. I had a lady who's foot was trodden on, by a large carer. I reported it to her GP and was very glad that I did and that I had writted the incident down in my work diary I now keep a separate 'Unusual Incident' file for all my Doms The Home tried to say I had caused the bruising by my treatment. Hope this helps, the main thing is 'cover your own back and don't trust anyone!!!' Best of luck with your career, I've had lots of laughs and made some wonderful friends with my patients over the. years
Carol

 

Thanks Carole this is just the reply I was after , I am after the modern approach, what an interesting incident too. I have a tablet find it great on the move hadn't thought about incorporated in my practise. Your advice was spot on. I am still new to proffesion so getting my bank of unusual events as of now.

 

Added extra, would your recommend podware4?

 

Hi again,
I'd highly recommend Pod4. I have used its predecessor Podware Pro for many years, at a different practice If you are setting up in private practice its perfect. it does your accounts, expenses CPD, and full patient records. For folk like me who hate admin it saves having to think! I'm not sure if it would load to a Tablet, it is something I'm about to find out. Its about £169 for a permenant Licence so its good value for money. The online clinic programes are expensive and not really worth having if you are on your own. They are designed for big practices. I hope John the creator of Podware is reading this and appreciates my comments! He was very helpfull when I bought a new laptop and had to transfer files.
Hope this helps
Carol

 

I can second that !!

I worked with john McCall developing Podiatry Practice Pro ( the original Podware) for private practice.

It is now as Podware 4 advanced beyond recognition from those days but John is still a great ambasador not only for his system but as a podiatrist in the world of diabetes.

Really nice guy, very approachable and helpfull :drinks

Cheers
D

 

Hello everyone,

I am a Pod in Canada, recently into private practice. Is Podware 4 available out here, is it adaptable enough for usage here, or can I take a closer look somehow?

I've been "listening in" for years, but this is my first posting. Thank you all!!

ToeGuyTom

 

Hi Tom



http://www.podware.co.uk/

If you follow this link it will take you to the podware site where you can download a free trial version. Try the contact us button and have a chat with John McCall who is the designer. He is a practicing pod specialising in diabetes and a very approachable chap.
I'm sure he will guide you :empathy:

Cheers
D

 

Hi Hannah,

I have pretty much given up doing care homes, because of the terrible attitude towards chiropodists, ( I have 1 left in Bournemouth if anyone with a stronger personality than mine is interested in taking on 'The Care Home Manager!!) Any how, In my current place, I make my own notes and write down and tell the duty manager of any special interest items. I also write who I have done in their 'chiropody book' with the concerns written there too. In my previous homes I always wrote in their care records too, but there was no specialist chiropody book there. I will not take on any more care homes, but a strong attitude and insistence of what you need is a must when starting in a new home.

Suzanne

 

GREAT advice - have had similar experiences! I write EVERYTHING down asap.......to transfer to computer later.

 

I do about 8 care homes and I find they all have a good attitude,

I keep my own notes obviously, and I advise the care home manager of which patients have been treated only, excepting if there is something of particular note when I add it to the basic information I have sent them.

Although you are only responsible to your employer which in this case is each individual patient, it would seem responsible to me on behalf of your patients. to do your best to fit in with whatever procedures the care home has in place.

 

Hi,

I devised a fairly simple form which I had made into duplicate pads, which I use for nursing homes. It has a foot health section, a 'treatment provided' section and a 'follow up care' section, where I note anything that I require them to do, unusual things I have found etc. The home then gets the top copy for there records, and I get the duplicate copy for mine, this acts as my notes which I write up as I go. The homes seem to really like this and there is no getting away from what I have asked/reported to them.

For my domicillary visits, Im interested in using a tablet or something whilst on the go. Does anyone have any experience of this, are any pod programmes compatible to use on one?

Many thanks
Nicki

 

Interesting to listen to the varied attitudes to working in aged care facilities.

I have full access to facilities files...write up care plan annually and separate allied health progress notes. Any incidents I write up a separate Handover sheet and discuss this with the Area RN and clinical coordinator. Part of cover your arse...

One new facility has gone computerised so I have my own login and am able to set alerts for patients etc.

Its a far cry from when I started 25yrs ago but I agree it helps if you have Big Brass Balls.

If you correct your attitude anything can be achieved...

 

Thanks DTT and Carol for the kind words about Podware4 and the standard of service that I strive to always achieve.

My apologies for not replying to this post earlier as I've been so busy.

Podware4 is available to practices in Canada, Australia, New Zealand and the USA. It's being used in Turkey, Spain, Hong Kong and Singapore too. The software can be used on a Tablet PC or most devices that have a windows operating system.
It can be viewed and edited on any device that can browse the internet if installed on a Windows machine and then accessed using some third party software on any mobile device such as a smartphone, iPad, Mac, Android tablet etc.

Having tried and tested a few my personal choice for mobile computing is an inexpensive netbook. Why? Because they are tougher when on the move, easier to use the keyboard, the battery on most will last in realistic use about 6 hours. It'll be carted in and out of the car, probably dropped at least once and the screens are less likely to get damaged.
Some of the Tablets are great but for business stick to Windows operating systems OR use the Tablet to access a windows PC that has your practice software installed.

I'm in the process of creating a web based (cloud computing) Podware4. The benefit is that it can be accessed from any device that can browse the internet. The data will be in 'the cloud'. Some will see that as an advantage - others won't want to trust their practice data to a server on the internet. It depends on how secure you perceive cloud data to be. There's a good article about it here:
Is cloud computing worth the risk

Hope this helps to answer any questions.

If there's anything else please contact me via PodiatrySoftware.co.uk

On the nursing home/note taking subject (podiatrist hat going on!) my advice is to write down as much of relevance that you can and, as Carol suggests, asap after treatment, if it isn't written down it didn't happen.
Keep your own records (electronic or paper), give a note of anything that needs done to the care home staff - preferably to someone who will ensure it's acted on, copy to the GP. In my experience good communication with the GP reaps rewards for you and the patient. If your only notes are in the nursing home care plans how do you access them in 2 years time when the patient relative is on the litigation warpath?? It does happen.