APA 4324 Clinical charting

Core characteristics of records

Records must be identifiable, legible, comprehensive, accurate, timely, accessible, retrievable, secure, and confidential.

Unique patient identifier

A unique identifier like a health card number; names and dates of birth are not considered unique on their own.

Handling record amendments

Indicate the change made, date, author, and reason for correction without destroying the original record.

Handling late entries

Clearly indicate that the entry is late and provide the reason for the delay.

Three types of records

1. Equipment service record, 2. Financial record, 3. Patient/client health file/record.

Retention for adult patients

At least 10 years for patients who are 18 or older at the time of the last contact.

Retention for minor patients

At least 10 years following the date the patient would have become 18 years of age.

Equipment service record retention

A minimum of 5 years.

Record destruction standard

Done in a secure fashion appropriate to the medium so records cannot be recovered, reconstructed, or identified.

Closing or transferring a practice

Store/transfer securely, notify patients of the future location of records, and transfer files if requested.

Patient access to files

Patients generally have the right to access and read their charts at any point, though fees for copies may apply.

Electronic record safeguards

Must be secure from loss, tampering, or unauthorized access, and retrievable throughout the entire retention period.

Controlled acts documentation

Must include reasonable information about the act performed and the authority (e.g., emergency, delegation) for it.

Incomplete or refused procedures

Must record reasonable information about the procedure and the reasons for non-completion or refusal.

Biopsychosocial Approach: Subjective Lifestyle Factors

Follow-up questions covering sleep, stress/anxiety, physical activity, nutrition, safety behaviours, and drug/alcohol use.

OPQRST Framework

A conversational framework covering Onset, Provocation, Quality, Region, Severity, and Timing.

OPQRST: Onset

What, how, and when symptoms occurred; main concerns and evolution of the condition.

OPQRST: Provocation

What increases or decreases symptoms, including specific history and daily living activities.

OPQRST: Quality

The kind of pain (sharp, dull, throbbing, burning) and description of discomfort (tingling, weakness, loss of mobility).

OPQRST: Region

Body parts disrupted; whether pain is local or radiates elsewhere.

OPQRST: Severity

Measured on a scale of 0-10.

OPQRST: Timing

Time of day, whether pain is constant or intermittent, aligned with patient-centered objectives.

Applying OPQRST to Sleep Habits

O: When it started; P: Worsening factors; Q: Onset, staying asleep, quality; R: Sleep position/comfort; S: 0-10 well-being scale; T: Desired bedtime/patterns.

Subjective Red Flags

Severe unremitting pain, pain unaffected by meds/position, severe night pain, severe spasm, and incontinence.

Objective Injury Assessment

Physical exam results, observations (posture, gait, swelling, redness), ROM, strength, and special/functional tests.

Objective Lifestyle Habit Assessment

Concrete observable results for overall health, sleep, stress/anxiety, physical activity, and nutrition.

Plan - Lifestyle habits

Includes a summary of interventions, priority goals, referrals, and future interventions with their parameters.

Interventions - Injury example

Includes recommendations, pharmacist consultation for OTC meds, posture education, MRI referral, MFR, and home program demo.

Interventions - Lifestyle example

Includes getting a planner, establishing a homework schedule, academic advisor referral, and neck stretches (3x30'' bilat).

Evaluation post-tx components

Assess patient understanding and agreement, feelings, re-test results, positive effects, and adverse effects with mitigation.

SIE follow-up notes

Subjective (new test results, condition changes, habit improvements) plus Interventions and Evaluation.

SOAPIE frequency guidelines

Acute MSK weekly, chronic biweekly, degenerative monthly, lifestyle when changing, and full SOAPIE for progress changes or new info.

Specific documentation guidelines

Specify body side, document everything, date, electronic lock, send PDFs, use pen, and sign with title and license number.

Amending hand-written charts

Use pen, strikethrough without hiding original text, and add initials and date next to it.

Amending electronic charts

Can amend until signed and locked; afterwards, use the specific electronic amendment button.

Discharge scenarios

Reached plateau, successful recovery, patient continues elsewhere, or no contact in 3 months after attempts to reach them.