|Year : 2022 | Volume
| Issue : 2 | Page : 41-42
Nourishing the art of clinical documentation – First step towards research
Suvarna Ganvir1, Rajeev Aggarwal2
1 Department of Neurophysiotherapy, DVVPF's College of Physiotherapy, Ahmednagar, Maharashtra, India
2 Senior Physiotherapist and In-Charge, Neuro-Physiotherapy Unit, NSC, A.I.I.M.S., New Delhi, India
|Date of Submission||22-Dec-2022|
|Date of Acceptance||26-Dec-2022|
|Date of Web Publication||31-Jan-2023|
Department of Neurophysiotherapy, DVVPF's College of Physiotherapy, Ahmednagar, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ganvir S, Aggarwal R. Nourishing the art of clinical documentation – First step towards research. Physiother - J Indian Assoc Physiother 2022;16:41-2
|How to cite this URL:|
Ganvir S, Aggarwal R. Nourishing the art of clinical documentation – First step towards research. Physiother - J Indian Assoc Physiother [serial online] 2022 [cited 2023 Jun 5];16:41-2. Available from: https://www.pjiap.org/text.asp?2022/16/2/41/368882
Clinical documentation in Indian physiotherapy practitioners is still in a nascent stage. On introspection, we found that for every action there should be a will. Now the question arises, whether there is a will among Indian physiotherapists to document whatever they practice. The will comes either with incentive or with compulsion. Incentives may be remuneration linked to clinical documentation as in developed countries. Insurance companies scrutinize the clinical papers submitted by physiotherapists for their payments. Other incentives may be the collection of data for future usage. On the other hand, there may a compulsion by the law of land to document every health service provided by any health-care professional.
As of date, none of the above factor is a driving force for physiotherapists of India to document their services. Then what can motivate them to adopt better documentation practices and what assistance can be provided for it or how can we nourish this art of clinical documentation?
Charter of patients' rights and responsibilities (As approved by the National Council for Clinical Establishments) aims to provide adequate relevant information about the nature, cause of illness, proposed investigations and care, expected results of treatment, possible complications, and expected costs; To seek the second opinion from an appropriate clinician of patients' choice, with records and information being provided by the treating hospital. These rights of the patient necessitate every health-care professional to maintain proper documentation, record it, and legitimate sharing of the documents.
Citizens of India are being equipped with their own clinical records which can be the motivation for clinicians to update their own clinical records to match with the standards set by the Ministry of Health and Family Welfare, Government of India. Ayushman Bharat Health Account under Ayushman Bharat Digital Mission, an initiative by the National Health Authority is helping Indian citizens to keep their clinical records in electronic format. It also helps to find the health-care professionals and share clinical records seamlessly with health-care professionals across India.
Considering these patient-oriented initiatives, it is high time that the documentation practice of physiotherapists be improvised so that it not only creates a strong database but can also be converted into authentic research which can be a foundation for evidence-based practice. How can one perfect this art?
On clinical rounds, a phrase is often heard "If it's not documented, then it didn't happen." Usually, this phrase is to alert junior staff and to encourage them to do documentation to avoid any lawsuits. It is not possible to document each and every action, interaction, observation, and conversation; therefore, it is imperative to know what is relevant to document. A clinical document is a properly dated, timed, concise, complete, accurate, and signed. It is a mode of communication with other health-care professionals, management, public administration, and judiciary. A therapist should develop a habit of documenting immediately after delivering the services. It helps in avoiding the risk of forgetting to document any important information. Abbreviations are generally avoided unless well accepted. It is a good practice to document consultation and telephonic advice received from other professionals or stakeholders. Effective clinical documentation is a skill which takes time to master and helps to improve the delivery of quality treatment. Systematic documentation and compilation of information generate substantial data to be used for research and administrative needs. British mathematician, Clive Humby (2006) quoted "Data is the new oil" that was further expanded by Michael Palmer. He quoted "like oil, data is valuable, but if unrefined it cannot really be used." In clinical practice, data generated by documentation can be a massive substrate for research. Retrieving retrospective data and refining it might bring out astonishing facts. Recently, a study presented in the International Spine and Spinal Injuries Conference 2022 (Nijhawan M and Singh V, unpublished) on demographic details of spinal cord injured persons in India in the past 10 years had some glaring facts, such as the proportion of female persons with spinal cord injury has doubled in the past one decade and poor visibility can be contributory to higher road traffic accidents observed in January.
Physiotherapy profession lags behind in establishing its virtue in health-care sector in India. The aversion of physiotherapists to adopt active documentation might be contributory to it. The habit of documentation will pave the way for the appropriate application and prescription of dosimetry such as type, duration, intensity, and frequency of physiotherapeutic interventions. Written words are considered to be immortal. Writing brings responsibility as well as ownership. This ownership will provide administrative and managerial roles to physiotherapists. The data generated through clinical documentation can facilitate economical evaluation and policymaking in respective physiotherapy areas.
The use of codes or using a standardized language for keeping notes is the foremost step. Subjective, Objective, Assessment, and Plan (SOAP) is the well-accepted format of clinical documentation. The SOAP note format is typically an initial pedagogy, as it requires clinical reasoning to develop treatment plans for an entire patient case. This has been replaced by consult notes, the International Classification of Functioning format in recent past which allows to record the functional status of patients which is of utmost importance in physiotherapy treatment.
Clinical documentation generates data which are valuable for patient-centered care which is meant to reduce morbidity and mortality. Furthermore, it has its own significance in the field of research creating evidence for evidence-based patient care. Proper documentation with pre- and posttreatment details may help to understand the mechanism of recovery with the given treatment which can be adopted by other physiotherapists, provided the information is shared on a common platform. This common platform can be clinical meets, informal discussions, conference proceedings/publications, or scientific talks at disease-specific conferences. This is a very effective way of communication among health-care professionals with specific data sharing. To facilitate this communication, the standard ways of documentation need to be adopted. Another way can be using computers for electronic health records as using electronic health records early in training may prevent mistakes in patients' medical records.
Clinical documentation is a hidden treasure if explored will pave the way for the scientific promotion and prosperity of physiotherapists. We wish all physiotherapists a very Happy and prosperous New Year 2023.
| References|| |
Pearce PF, Ferguson LA, George GS, Langford CA. The essential SOAP note in an EHR age. Nurse Pract 2016;41:29-36.
Tully M, Carmichael A. Computer-assisted coding and clinical documentation: First things first. Healthc Financ Manage 2012;66:46-9.