Recording the right details for your notes

Once you are taking notes every for every consultation you need to make sure you are recording the right details. There's no value to a note with hardly anything in it. Likewise, if you record too much information, or do it long hand, you are wasting time you could be spending with patients or on building your practice.

There are two important considerations for Allied Health clinical notes, both of which should be understood before taking further actions on the details you record in your notes. The first is that Allied Health notes are different to Doctor’s notes. The second is that standard note taking should be adjusted to better fit with Allied Health requirements.

Allied Health clinical notes

Unlike Doctors, Allied Health clinical notes fall into two distinct categories. Notes recorded for initial consultations or reviews, which record more detail, and treatment notes which record less. You need to understand how these two types of notes are different in order to record the right details. Record too little in an initial consultation and you won’t know what’s going on with your patient, record too much information in a treatment and you will be wasting your time.

Initial consultations and reviews book end your treatments

Initials consultations and reviews are similar to a patient visiting a GP where a particular presenting complaint is discussed. Detail of the complaint is recorded, the necessary tests and observations are performed and a working diagnosis is detailed. Then a treatment plan is put in place, which for the GP example could be a treatment of medicine. There is often a follow up review to discuss progress and update the treatment plan if required.

It is no different for Allied Health. The initial consultation records many of the same details, presenting complaints, tests, assessment/diagnosis and a treatment plan. All of these elements should be well documented so that when it comes time to review patient progress it is clear what progress has been made and how ongoing treatments need to be adjusted.

The treatment plan should note the frequency of treatments and when the next review is planned.

Reviews then record substantially the same information, updated to reflect the progress since the initial consultation or the most recent review. Subjective details of the complaints should be updated based on patient details. Tests should be re-done and the updated results recorded and an update to the working assessment/diagnosis should be added to the note.

An update to the treatment plan can be made at the review based on the new working diagnosis and how the patient has responded to the intervening treatments.

Treatment consultations are the equivalent of medicine

Treatment consultations are where there is a substantial divergence from GP’s. Each treatment is a return consultation for the patient where they will be present in your practice. The details of the initial consultation or any reviews should be available to check and update if necessary but the primary note taking requirement is a record of the treatment itself.

With regular consultations your working diagnosis can be updated more frequently as a patient responds to your treatments, and the forward treatment plan can be adjusted as necessary.

The primary focus will be recording the details of the treatments you have performed directly, depending on your particular Allied Health profession, as you deal with a patients particular presenting complaints.

Approaches to clinical note taking

There are a number of recognised approaches to clinical note taking, many of them developed first for GP’s.

One of the most commonly used approaches is the SOAP Note (Subjective, Objective, Assessment, Plan). This style of note provides a structure to record relevant detail for a clinical consultation. There are a number of other approaches but, while they tend to have slightly different focuses, they record generally similar details.

For Allied Health professionals the SOAP Note can provide a reasonable structure to record notes, although we recommend a modified version that more accurately captures the treatment consultation differences of Allied Health Practitioners.

So, if you are struggling to find guidance for your note taking, or the guidance published by your regulatory body isn’t details enough, we would suggest building a template which included the following modified SOAP Note details, with the Plan section split into Shedule, Treatment and Home Care.

Subjective

Record all relevant information provided by the patient, including:

  • How they are feeling overall

  • What goals they have for their health

  • The details of all complaints for which they are seeking treatment

  • Capture an overall informed consent during an initial consultation

Objective

Record all relevant professional observations you make when examining the patient, including:

  • Results of all tests performed

  • Range of motion observed

  • Pain and posture information

  • Attaching documents provided by external healthcare providers

Assessment

Record your professional diagnosis for the patient based on the subjective information provided and objective observations, including:

  • Overall diagnosis for the patients condition, potentially multiple diagnoses if there are multiple presenting complaints

  • Any underlying medical conditions which could impact a patients response to treatment

  • Any changes in diagnosis as a result of treatment or other factors

Schedule

Record the planned schedule for achieving the patients health goals or resolving complaints.

Treatment

Record all treatments performed during the consultation, including:

  • Type of treatment

  • Focus of the treatment, eg Muscle, Bone, Joint, Cranial etc

  • Location of treatment

  • The method of application for a specific treatment, if applicable

  • Treatment failures, where observable

  • Any referrals that are made to other health providers

  • Recording of informed consent obtained for individual treatments, if that is required in your profession

Home Care

Record all recommendations for a patient to perform outside of your practice, including:

  • Medications, supplements or other products prescribed

  • General lifestyle recommendations, eg Sleep more, drink more water

  • Exercises to be undertaken

As discussed above, for Allied Health professionals, the Subjective, Objective and Assessment notations are generally recorded and updated during initial consultations and reviews. The relevant Schedule, Treatment and Home Care details are recorded in every consultation; initials, reviews and treatments.

Clinical note taking regulations

The second main consideration is that, for many professions in many countries, there are specific regulations in place governing clinical note taking to ensure it is correct, complete and reflects the treatments that have taken place.

In some cases there will only be some general guidelines in other cases there will be detailed guidance covering what should be recorded and when.

If you don’t know the requirements, or haven’t checked up on any changes since you completed your degree, you could be opening up your practice to risk (which is often time spent on courses to make sure you understand the requirements, but it’s time better spent on other things).

Take action

Now you have the background on the detail of Allied Health clinical notes we can talk actions.

We recommend the following to improve the details you are recording:

  1. Know your regulations

  2. Think through other considerations for recording the right details

  3. If you use electronic notes, understand what they can do for you

Know your regulations

Most professions in most countries will publish recommendations and guidelines on clinical note taking, often publicly on their web site, so it can be relatively easy to find the details. You may have to contact your association or regulatory body for more details if the guidelines are note easily accessible.

Here are some quick links to help:

The regulations themselves should cover the different information required for initial consultations compared to treatments.

Once you have access to your specific guidelines we recommend:

  • Reviewing them against the note taking templates you use in your practice. Where you find gaps or inconsistencies you may need to make changes to your templates.

  • Review them against a selection of clinical notes for each of the practitioners in your practice. Your templates may be able to record all the required details but if your practitioners are not using all the sections, or they are not providing enough detail then you may still have notes which are not effective to your practice. Run education sessions if your team requires it.

Remember, if you are using your own paper notes or building an electronic template, you are responsible for ensuring that the templates are able to capture all the information required by the regulations. If there is a deficiency in your notes it won’t be acceptable to claim that your templates didn’t have space or fields to cover off the requirements.

If you are unable to find regulatory guidelines for your profession then check your current note templates against the SOAP note approach to clinical note taking outlined above. We’ve tailored it to Allied Health and it provides a solid starting point for clinical notes. If you find gaps in your current note taking templates work out what alterations you could make to cover them off in the future.

Other note taking considerations

There are a few other thoughts and actions that you should consider when building effective clinical notes for your practice. Some will be required by regulation and others will be useful to ensure the best outcomes for your patients.

Have all patient clinical details in one place and hide the rest

There is often little time between consultations to check in on a patient’s history, current complaints and most recent treatments. Having all this information in one place greatly simplifies building a complete picture for a patient before you start your treatment.

Clinical notes, attached documents, medical alerts, general reminders and patient overview should all be in a single place and easy to access so you can keep your knowledge of a patient up to date and your treatments on track.

It's also important to keep your patient file focused on what you need to treat your patients. Having invoices, payments, recalls and other administrative details mixed in with you patient file will distract you from the important focus you need during a treatment.

Check how your current note taking is organised. Make sure that all clinical and treatment related notes are in one place and, ideally, that other patient details are not creating distractions. You should be able to get to everything easily to minimise the time it takes to review a patient’s history before a consultation and to make sure that you have all the information available to provide the best treatment outcomes.

Legibility and understanding

Many regulators have a general recommendation that an alternative practitioner should be able to read your notes and understand exactly what is going on with a patient, what the plan is for them and what treatments have been performed.

Achieving this requires to specific approaches when taking your notes:

  • Your notes muse be legible, particularly important if you are using paper notes

  • Your notes must be understandable, particularly if you use shorthand codes to describe treatments

Legibility tends to be a issue with paper note taking. The handwriting of each practitioner can be very different, and in some cases is it can be difficult for one practitioner understand what another has written. If you are using paper we recommend the following:

  • Write in all caps, even if you are unable to understand an individual’s writing you can often understand all caps

  • Design a form which minimises writing and instead use tick lists

  • Consider moving from paper to electronic notes, as legibility issues are automatically reduced

Understanding can be much more complicated. Many Allied Health professionals use short hand codes and other notations to represent the treatments that have been performed during a consultation. Shorthand may be easily understandable by the practitioner making the notation but have no relevance at all to another practitioner.

To ensure your notes are clearly understood we recommend the following:

  • Create a list of abbreviations that are used in your practice, including what each abbreviation means

  • Ensure that all practitioners have a copy of the list and understand that they must use them

  • Schedule a review once a quarter to ensure that everyone is using the correct terms and abbreviations, this should include reviewing a sample of notes

  • Where possible build standard abbreviations into your paper or electronic notes so that they can be selected rather than being individually written

This is particularly important if you are making custom notations that are not immediately recognised by other members of your profession. It can often be the case that different practitioners are using the same short notation to mean completely different things. If your patient sees a different practitioner, and they rely on a code to inform their treatments which does not mean what they think it means, this could lead to poor treatment outcomes for the patient and risk for your practice.

Check what shorthand notations you are using in your practice. Make sure that you have an index available for all those notations and have all practitioners agree on standard descriptions for every shorthand notation in use. If a short term replacement is covering for you, or a patient needs you to send their notes to another practitioner, then provide the index alongside any history so your short hand notations are clearly understandable.

Understand your software

Electronic clinical notes tend to fall into two categories.

The first has four fields to capture SOAP details for you patient note. Often there will be some macros which will pre-fill some text to save on typing, but the result is still a text note.

The second will allow you to create a note template customised to you. Specific question and answer fields, pick lists and other options will be available which allow for a more structured note to be recorded. The results are still stored as text for the note.

In both cases an attachment system, perhaps allowing hand written notations, will also be included.

It’s worth in all these cases digging in to work out if the notes have further features which will improve your note taking or your practice as a whole. Jump into the online help documentation to see what’s available.

Areas worth exploring:

  • Can you easily see an overview of the patient, including what complaints you are tracking with recent progress (without having to work through all your notes one by one)

  • Is it easy to track a patients attendance against the appointment plan that you have set

  • Are you able to clearly see and edit medical alerts while you are recording notes

  • Can you control what short cut codes represent so there is commonality inside your practice

This is by no means an exhaustive list, but if your electronic notes can provide better information it’s worth utilising that to improve your note taking and practice efficiency.

Take your time

There are often substantial guidelines in place for note taking (Australian Chiropractors have multiple pages) and your note templates may not cover everything that’s required. It’s better to add new sections and details progressively, taking the time to get used to how a section works and embed it into your work flow, rather than trying to add everything you find at once.

Want to learn more

This article is part of the series “Effective clinical note taking for Allied Health practitioners”. Please see the other emails in the series for further details and recommendations. If you were sent this link directly and want to subscribe to the whole series, please sign up.