Concept given by Shacklock (modern concept) and Butler (old concept), a method of assessment as well as treatment of peripheral neurological system by physiotherapists.
Part-I: The current slideshow: theoretical aspect of neurodynamics.
Part-II: Assessment of peripheral nervous system on the basis of neurodynamic concepts: Date: 01/04/2020
Part-III: treatment part: Date: 03/04/2020
Part-IV: Self neurodynamics: 05/04/2020
A highly structured, goal-oriented, individualized intervention program designed to return the employee to work. Our Work Hardening programs are multidisciplinary in nature and utilize real or simulated work activities designed to restore physical, behavioral and vocational functions.
Mandatory to learn to classify various sorts of disabilities and dysfunctions occurring due to impairment and making physically handicapped either due to hampering in the physical functions.
Concept given by Shacklock (modern concept) and Butler (old concept), a method of assessment as well as treatment of peripheral neurological system by physiotherapists.
Part-I: The current slideshow: theoretical aspect of neurodynamics.
Part-II: Assessment of peripheral nervous system on the basis of neurodynamic concepts: Date: 01/04/2020
Part-III: treatment part: Date: 03/04/2020
Part-IV: Self neurodynamics: 05/04/2020
A highly structured, goal-oriented, individualized intervention program designed to return the employee to work. Our Work Hardening programs are multidisciplinary in nature and utilize real or simulated work activities designed to restore physical, behavioral and vocational functions.
Mandatory to learn to classify various sorts of disabilities and dysfunctions occurring due to impairment and making physically handicapped either due to hampering in the physical functions.
Clinical reasoning is one of the pillars for good physiotherapy practice. It is an integral component of evidence based practice. It is a thought process that develops over time in a clinician. The first step is to start thinking of a clinical problem.
The lecture is delivered to first year physiotherapy students at Kathmandu University School of Medical Sciences, Nepal. The students will continue with case discussion using similar model proposed by Mark Jones and Darren Rivett in his book. Further real cases and the cases in Mark Jones will be discussed in the subsequent classes over the Bachelor of Physiotherapy course.
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
Brian Mulligan described novel concept of the simultaneous application of therapist applied accessory mobilizations and patient generated active movements
A very old school of manual therapy which comprises of two main principle centralization and peripheralization thought given by Robin McKenzie. The slideshow explain theoretical and practical part of both entire spine and extremities as well
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
NDT, BOBATH TECHNIQUE, BASIC IDEA OF BOBATH, CONCEPT OF BOBATH, NEUROPHYSIOLOGY OF NDT, ICF MODEL, PRINCIPLES OF TREATMENT OF NDT IN STROKE AND CP, AUTOMATIC AND EQUILIBRIUM REACTIONS, KEY POINTS OF CONTROL, FACILITATION, INHIBITION AND HANDLING IN NDT
Neurodynamics, mobilization of nervous system, neural mobilizationSaurab Sharma
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
Clinical reasoning is one of the pillars for good physiotherapy practice. It is an integral component of evidence based practice. It is a thought process that develops over time in a clinician. The first step is to start thinking of a clinical problem.
The lecture is delivered to first year physiotherapy students at Kathmandu University School of Medical Sciences, Nepal. The students will continue with case discussion using similar model proposed by Mark Jones and Darren Rivett in his book. Further real cases and the cases in Mark Jones will be discussed in the subsequent classes over the Bachelor of Physiotherapy course.
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
Brian Mulligan described novel concept of the simultaneous application of therapist applied accessory mobilizations and patient generated active movements
A very old school of manual therapy which comprises of two main principle centralization and peripheralization thought given by Robin McKenzie. The slideshow explain theoretical and practical part of both entire spine and extremities as well
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
NDT, BOBATH TECHNIQUE, BASIC IDEA OF BOBATH, CONCEPT OF BOBATH, NEUROPHYSIOLOGY OF NDT, ICF MODEL, PRINCIPLES OF TREATMENT OF NDT IN STROKE AND CP, AUTOMATIC AND EQUILIBRIUM REACTIONS, KEY POINTS OF CONTROL, FACILITATION, INHIBITION AND HANDLING IN NDT
Neurodynamics, mobilization of nervous system, neural mobilizationSaurab Sharma
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
The organization provides care and services that achieve effective outcomes and ensures that the correct consumer /patient receives the correct procedure
ITS IMPORTANT TO MEET THE COMPETENCES (Thats how they evaluate the mariuse18nolet
ITS IMPORTANT TO MEET THE COMPETENCES (That's how they evaluate the work).
Nursing within an organization is a critical component of health care delivery and is an essential ingredient in patient outcomes (Kelly & Tazbir, 2014). The concern for quality care that flows from evidence-based practice generates a desired outcome. Without these factors, a nurse cannot be an effective leader. It is important to lead not only from this position but from knowledge and expertise.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Competency 2: Explain the accountability of the nurse leader for decisions that affect health care delivery and patient outcomes.
(IMPORTANT) -Describe accountability tools and procedures used to measure effectiveness.
Competency 3: Apply management strategies and best practices for health care finance, human resources, and materials allocation decisions to improve health care delivery and patient outcomes.
(IMPORTANT) -Develop an evidence-based plan for health care delivery.
Competency 4: Apply professional standards of moral, ethical, and legal conduct in professional practice.
(IMPORTANT) -Apply professional and legal standards in support of a care plan.
Competency 5: Communicate in manner that is consistent with the expectations of a nursing professional.
(IMPORTANT) -Write content clearly and logically, with correct use of grammar, punctuation, mechanics, and current APA style.
Preparation
Refer to the Capella library and the Internet for supplemental resources to help you complete this assessment.
Instructions
Deliverable:
Develop an evidence-based plan for health care delivery.
Scenario:
The hospital where you work has an issue with increased readmissions within 30 days of discharge. After examining the core measures, it was found that heart failure was the most common core measure disease process experiencing the highest rate of readmissions. The leadership team has given your team the charge of developing a nurse-run outpatient heart failure clinic. The purpose of this clinic is to ensure that discharge education is presented to the patient in an orderly, consistent manner and complies with evidence-based practice protocols. Since these patients may be discharged from a variety of areas in the facility, having the heart failure clinic staff take ownership of the process will improve both consistency and compliance. There are cardiologists that interact with the staff and patients, but the day-to-day operations of the clinic are designed and supported by the nurses as they interact with appropriate members of the other health care team disciplines promoting the best care for the heart failure patients.
As a member of the nurse team, you have been asked to develop
one
component
of the clinic.
The hospital leadership established these objectives ...
Write a 3 page evidence-based health care delivery plan for one .docxowenhall46084
Write a 3 page evidence-based health care delivery plan for one component of a heart failure clinic.
Nursing within an organization is a critical component of health care delivery and is an essential ingredient in patient outcomes (Kelly & Tazbir, 2014). The concern for quality care that flows from evidence-based practice generates a desired outcome. Without these factors, a nurse cannot be an effective leader. It is important to lead not only from this position but from knowledge and expertise.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Competency 2: Explain the accountability of the nurse leader for decisions that affect health care delivery and patient outcomes.
Describe accountability tools and procedures used to measure effectiveness.
Competency 3: Apply management strategies and best practices for health care finance, human resources, and materials allocation decisions to improve health care delivery and patient outcomes.
Develop an evidence-based plan for health care delivery.
Competency 4: Apply professional standards of moral, ethical, and legal conduct in professional practice.
Apply professional and legal standards in support of a care plan.
Competency 5: Communicate in manner that is consistent with the expectations of a nursing professional.
Write content clearly and logically, with correct use of grammar, punctuation, mechanics, and current APA style.
In an effort to improve the patients' health literacy concerning heart failure, it is important that the clinic staff and the hospital staff present a consistent, evidence-based message on self-care to these patients and their families in order to decrease acute exacerbation and re-admissions. Review current evidence for clinical practice guides or protocols when developing your patient teaching plans and materials. Consider the following:
What does the patient know about the disease process as a baseline?
What does the patient need to do understand as far as the best self-care processes?
Can the patient identify proper medication compliance?
Is there a financial issue that affects compliance?
Who buys and prepares the food in the home?
Can the patient verbalize when to seek medical assistance?
Instructions
Deliverable:
Develop an evidence-based plan for health care delivery.
Scenario:
The hospital where you work has an issue with increased readmissions within 30 days of discharge. After examining the core measures, it was found that heart failure was the most common core measure disease process experiencing the highest rate of readmissions. The leadership team has given your team the charge of developing a nurse-run outpatient heart failure clinic. The purpose of this clinic is to ensure that discharge education is presented to the patient in an orderly, consistent manner and complies with evidence-based practice protocol.
MOTOR RELEARNING PROGRAM- A physiotherapy approch.pptxSusan Jose
Motor relearning is a frequently used mode of retraining neurologically assaulted patients.lets explore the principles and examples of relearning movement.
Gait training Physiotherapy perspective.pptxSusan Jose
do you know what is gait?
lets know more this presentation.
can physiotherapist help you with your walking abilities. click on the above slide to know more.
gait assesment is a critical componet of physiotehrapy assesemnt. physiotherapist does qualitative and quantitative assesment to find impairements.
It includes observational gait analysis, spatiotemporal parameters.
Pain is a very distressing sensation.
To treat pain it is important to understand how it is perceived and internally control by the body itself.
Here in this presentation you will understand how normally pain is perceived and how normally our body controls it.
This is a brief overview of various aspects of the higher mental functions. Namely
memory
orientation
attention
communication
perception
executive functioning
these needs to be assessed using screening and categorizing tools such as MMSE and MoCa
This scale is used to categrise spinal cord injury patients. it helps prognosticate the spinal cord injuires. it also helps define the treatment protocols for spinal cord injury patients. American Spinal Cord Injury Association made this scale so as to make a standardization in assesemnent technique in acute spinal cord injury patients.
Assessment of body composition , strength, endurance, flexibility agility power coordination speed . tests for all the above mentioned components. health and skill related physical fitness
Neurodevelopemental Therapy (Bobath approach)- Principles and EvidenceSusan Jose
Here we present a widely used neurophysiotherapeutic approch - NDT, exploring its current principles and throwing a glance at the historical development and why it is being so widely practice.
does it really have that evidance base?
Find more as you click on. Give a like if I helped you learn or clear concepts. Thankyou. Love you all. Lets learn more.
Geriatric Rehabiltation- A detailed go throughSusan Jose
Here we, Dr. Kiran (PT), and I, present a detailed overview of geriatric rehabilitation along with the dosage. Age related changes in posture its associated neurophysiology and compensations adapted by the elderly are also decribed in easy to learn way. The pathomechanics of fractures have been illustarted in easy to learn method too.
Resident as Teacher workshop slideshow on ReflexesSusan Jose
This ppt shows how to teach a student rather than what to teach a student include maximum examples and make your lecture in to imaginative and understanding experience to the child.
Visual perception from the point of view of Sensory IntegrationSusan Jose
we include the anatomy and neurophysiology of the visual system.the functions and how its importance. assessment of processing disorders is also included.
we include clinical features and management of visual processing disorders. A recent advance related to management of visual processing disorder has been attached at the end.
Here discuss some important bio mechanical aspects of the orthosis we use use in daily physio-therapeutic rehabilitation.
We also discuss the principles under which all the orthosis works. references are various articles from pubmed. For furthur read refer Atlas of orthosis and assistive aids.
Temple fays and phelps approach in neurophysiotherapy and cerebral palsySusan Jose
Temple fays and Phelps approach in Neurorehabilitation
THESE ARE THE OLD SCHOOLS OF NEUROREHAB BUT WE HAVE A LOT TO INCULCATE FROM OUR ROOTS AND LEARN FROM THE HISTORY SO THAT WE DON'T REPEAT THOSE MISTAKE AND MAKE NEW ADVANCES.
LIKE AND SHARE
BUILD.BACK.BETTER
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Struggling with intense fears that disrupt your life? At Renew Life Hypnosis, we offer specialized hypnosis to overcome fear. Phobias are exaggerated fears, often stemming from past traumas or learned behaviors. Hypnotherapy addresses these deep-seated fears by accessing the subconscious mind, helping you change your reactions to phobic triggers. Our expert therapists guide you into a state of deep relaxation, allowing you to transform your responses and reduce anxiety. Experience increased confidence and freedom from phobias with our personalized approach. Ready to live a fear-free life? Visit us at Renew Life Hypnosis..
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
From navigating policy options to staying informed about industry trends, this comprehensive guide explores everything you need to know about the health insurance market.
Welcome to Secret Tantric, London’s finest VIP Massage agency. Since we first opened our doors, we have provided the ultimate erotic massage experience to innumerable clients, each one searching for the very best sensual massage in London. We come by this reputation honestly with a dynamic team of the city’s most beautiful masseuses.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
2. OBJECTIVES
• Definition and need of documentation
• Guidelines for documentation
• Types of documentation
• Ways of record entering
• Types of clinical notes
• Informed consent
• Confidentiality
• Maintenance and destruction of documents
3. • CONCLUSION: Out of 100 records only 4.3% achieving a rate of 100 per cent completion In
total, and 81.7% were at least 50 per cent completed, which was considered a reasonable
overall standard. While the overall standard of documentation was deemed acceptable, it was
clear there was room for improvement.
4. • CONCLUSION: Findings from the study suggest that physiotherapy documentation accuracy
needs to be improved in order to promote optimal continuity of care, improve efficiency and
quality of care, and recognize patients’ needs and adverse events. Due to poor documentation,
it was not possible to establish a relationship between the accuracy of physiotherapy report
about the admission of patients and physiotherapy diagnoses, interventions, and progress and
outcome evaluations.
5. INTRODUCTION
• DEFINITION: Documentation is a material that provides official
information or evidence and that serves as a record.
• Medical records are the important tools to perform the affair of
treatment and prevention and are known as the reflecting mirror of the
medical affairs in an institute.
• Documentation is used as the foundation of the programming and
decision making management in education, research and health, are
the most valuable criteria of hospital staff professional assessment.
• Documentation of medical records is often used to protect the
researches, train medical care staff, general studies and qualitative
studies.
6. General guidelines for documentation:
Documentation is required for every visit/encounter.
All handwritten entries shall be made in ink and will include original
signatures. Electronic entries are made with appropriate security and
confidentiality provisions.
Errors should be corrected by drawing a single line through the error ,
signing and dating the entry or through the appropriate mechanism for
electronic documentation that clearly indicates that a change was made
without deletion of the original record.
7. All documentation must include the patient's/client's full name and
identification number. All entries must be dated and authenticated with
the therapist's full name and appropriate designation.
Documentation should include indication of no shows and
cancellations.
Documentation by graduates or physical therapy assistants shall be
authenticated by a licensed physical therapist.
Documentation should include the referral mechanism by which
physical therapy services are initiated.
Ex: Self-referral/direct access
Request for consultation from another practitioner
8. Areas of
documentation in
physiotherapy
Home visits
. Financial records
. Patient evaluation
and progress records
Referral records
Clinics
. Financial records
. Patient evaluation
and progress records
Referral records
Hospitals
Patient
-OPD
-IPD
Departmental records
Staff Record
Equipment records
Hospital cum
college setups
Patient
-OPD
-IPD
Staff Record
Equipment records
Student records
9. WAYS OF DOCUMENTATION:
MANUAL ENTERING:
It is a paper and pen method of entering the data , stored by filing in folders.Legally
they are more acceptable as a documentary evidence ,as these are difficult to tamper
with.
Disadvantage-
The need for large storage areas and difficulties in the retrieval of records
ELECTRONIC HEALTH RECORDING:
• The medical records are computerized. These are neat and tidy, and can be easily
stored and retrieved. These require a mandatory password protection and backup
system. Access to these safety software is only given to authorized personnels.
10. Types of documentation
1. Demographic records
2. Clinical notes records
3. Departmental records
4. Financial records
11. DEMOGRAPHIC RECORDS
Demographic data is a objective characteristics of a population such as:
-Age, Gender, marital status, family size, present or prior disease, blood
group, Income, education & residency.
USES:
This information helps the care team communicate effectively with
patients, as well as understand a patient’s culture, which may affect their
health. By knowing more about the patients that we can serve better.
12. • Clinical Health records are accurate, complete, authenticated and
legible information gathered in a timely manner by health care
professionals regarding the mental or physical state of a client.
• Record writing pertains to a systematic way of putting together
information regarding the client.
CLINICAL HEALTH RECORDS:
13. Uses of clinical records writing:
1. Provides a standardized way of communication in the multidisciplinary
team.
2. In a multidisciplinary team, clinical record is a way for continuation and
coordination in patient care.
3. Aids informed decision making for patient management.
4. Aids targeting of diagnostic tests and treatment plans without unnecessary
repetition.
5. Early diagnosis = more time spent in treatment.
6. Help in analyzing the treatment results.
7. Help in the scientific evaluation of patient profile.
8. Provides information in legal cases and for claiming insurance.
9. Improves time management.
15. Record writing for Evaluations
Subjective Chief complaint in terms of functional limitation
History
Pain history
Ex-
I cannot properly left lift my leg on my own
I lose balance while walking.
HOPI: Patient had stroke 3 weeks ago, he had a loss of sensation
and weakness on R side of his body.
Past medical: HTN, diabetes mellitus since 3 years and was
poorly controlled
Personal history: Chronic Smoker, alcoholic.
S.O.A.P Format
16. Objective Systems Review
Tests
Measurements
Outcome measures- Disease specific
Ex-
Voluntary Control lower limb – poor
Spasticity of gastrosoleus – 2
BBS-24
Feugal Meyer score- 94 (moderate affection)
Sensations- deep sensations diminished
Observational gait analysis- circumductory gait
Spatiotemporal gait assessment- reduced gait speed and
shorter left side step length.
17. Assessment
(Analyse)
Reason and correlate the subjective, objective findings, activity
and participation limitations.
Diagnosis by the physical therapist shall include impairment,
activity limitation, and participation restrictions.
Ex-
The 40 yr old male is a subacute c/o hemiparesis who came with
c/c of losing balance while walking.
The spasticity, reduced voluntary control and diminished deep
sensations have lead to decreased static and dynamic balance.
The reduced standing balance have lead to gait deviations.
There is inadequate sequential activation of muscle groups of the
left lower extremity.
19. Plan of care Short term and long term goals to set.
Goals shall be stated in measurable terms that indicate the predicted
level of improvement in functioning, proposed duration and frequency
of service required to reach the goals.(SMART)
Anticipated discharge plans.
A general statement of interventions to be used.
Ex- Short term goal: thrice in a week for 3 months
Patient should walk without fall of fear for 500m on even ground
Patient should be able to walk with an assistive device for 200m on uneven
ground.
-spasticity management
-Balance training
-Strengthening
-Gait training
Long term goal: twice in a week for 3 months
Patient should walk without assistive device for 1km on uneven surface.
Patient should be able to use transport independently.
-Endurance training
-Balance training
20. Record writing for subsequent Visits:
It is important in the patients who daily improvement is expected.
Ex- musculoskeletal conditions.
Patient self-report (as appropriate).
Record of specific interventions provided, according to the FITT criteria of
exercise prescription. (frequency, intensity, type of exercise and time/duration)
Ex: ten repetitions , three sets, 1kg weight, concentric Knee extension.
Equipments provided.
Ex- cane, AFOs
21. Changes in patient impairment, activity limitation, and participation restriction
status as they relate to the plan of care.
Response to interventions, including adverse reactions, if any.
Referral notes.
Documentation of plan for the next visit, that may include:
The interventions to be added with objectives
Progression parameters
Precautions, if indicated
22. Record writing for Patients on review
Documentation of selected components of examination to update patient's
functioning or disability status.
Patient adherence to patient-related instructions.
Interpretation of findings and, when indicated, revision of goals.
When indicated, revision of plan of care, in correlation with documented goals.
23.
24. Discharge Record writing:
• Current physical/functional status.
• Degree of goals achieved and reasons for goals not being achieved.
• Discharge plan related to the patient continuing care.
• Home program.
• Referrals for additional services.
• Recommendations for follow-up physical therapy care.
• Family and caregiver training.
• Equipment provided.
• Caution notes- in situtations to consult a healthcare professionals.
25. INFORMED CONSENT
• Informed consent is a decision to participate in assessment, treatment or research,
taken by a competent individual who has received and understood the necessary
information. If the patient is younger than 18, a parent/guardian will need to give
consent.
• Competent individuals should be provided with adequate, intelligible information
about the proposed physical therapy. This information should include a clear
explanation of:
• the planned assessment
• the evaluation, diagnosis, and prognosis/plan
• the treatment to be provided
• the risks which may be associated with the intervention
26. • the expected benefits of the intervention
• the anticipated time frames
• the anticipated costs
• any reasonable alternatives to the recommended intervention
• If a medical practitioner attempts to treat a person without valid consent, then
the patient may sue the medical practitioner in case of negligence.
• He will be liable under both civil and criminal law. The consequences would be
payment of compensation (in civil) and imprisonment (in criminal).
• In certain extreme cases, there is a theoretical possibility of criminal prosecution
for assault or physical contact with another person without that person's consent.
28. • Confidentiality is the principle of maintaining the security of
information elicited from an individual in the privileged circumstances
of a professional relationship.
• It covers:
• Patient physical and mental health
• Any clinical information related to individual’s diagnosis and
treatment
• Photographs, video and audio tapes.
29. Privacy violations in the healthcare sector include :
• Disclosure of personal health information to third parties without
consent/inadequate notification to the patient.
• Unnecessary collection of personal health data
• Provision of personal health data to public health, research, and
commercial uses without de-identification etc..
30. Where disclosure of personal health information is
permitted
• During referral
• When demanded by the court or by the police on a written requisition
• When demanded by insurance companies as provided by the Insurance
Act
• When required for specific provisions of workmen's compensation
cases, consumer protection cases, or for income tax authorities
• Communicable disease investigations and registration
31. Types of documentation
1. Demographic records
2. Clinical notes records
3. Departmental records
4. Financial records
32. •These are the statistical records regarding the number of patients
,status of equipments and the revenue generated. The statistics are
calculated bimonthly or monthly and yearly.
• Daily attendance of the patients reporting to the department should
be made, categorisation shall be done according to the purposes of the
visit.
•No. Of evaluations
•Patients on follow-ups.
•Number of discharges.
•No. of treatment sessions
•Attendance of the staff .
Departmental records
33. • Number and status of equipments - Equipment maintenance register
is to be maintained. Warranty notes should be filed with the date of
purchase and cost of the item. Servicing timings should be charted .
• Maintenance of charts to aid servicing of safety equipments .
• Ex- fire extinguisher, first aid, defibrillator kit etc.
• Maintainace of cleanliness record regarding the frequency of
departmental pest control and disinfection.
34. Uses of Departmental record writing
1. The departments needing more attention and resources can be
identified and hence the resources namely, equipments, space and
manpower can be redistributed.
2. Helps the owner in planning infrastructural and manpower
strategies for future medical care.
3. Helps in auditing the quality of healthcare services.
4. The progress of each department can be monitored and appropriate
actions can be taken.
35. FINANCIAL RECORDS
• Financial statements are used to give you much more than just a
snapshot of your business health.
36. FILING & ARRANGING OF RECORD
• Introduction
Medical records in most health care institutions are filed numerically according to patients
medical record numbers. In the past, some hospitals have filed records according to patients
names, discharge numbers, or diagnostic code numbers. Alphabetic filing by patient names is
more cumbersome and subject to more error than numerical filing. Filing by discharge
numbers and diagnostic code numbers is generally unsatisfactory because other important
records or registers in the facility are concerned exclusively with medical record numbers
1. Numbering System
Three types of numbering systems are currently in use in health care facilities.
They are:
Serial Numbering System.
Unit Numbering System.
Serial Unit Numbering System.
37. 1. Serial numbering:
In serial numbering the patient receives a new number each time he is
registered or treated by the hospital. If he is registered five times, he
acquires five different medical record numbers.
38. 2. Unit numbering:
• Unlike the serial numbering systems, the unit numbering system provides a
single record, which is composite of all data gathered on a given patient,
whether as an outpatient, inpatient or emergency patient.
• The patient is assigned a medical record on his first visit, which is used for all
subsequent visits and treatments.
• His entire medical record is thus in one folder under one medical record
number.
39. 3. Serial unit numbering:
This numbering system is a combination of the serial and unit numbering
systems. Although each time the patient is registered he receives a new medical
record number, his previous records are continually brought forward and filed
under the latest issued number.
Annual numbering:
Serial numbering that includes the last two digits of the current calendar year,
may be used by hospitals that primarily serve a transient population. In this
system, the two digits for the year are added to the end of a serial number.
40. Family numbering:
• Another adaptation of unit numbering is the family numbering system. Family
numbering usually consists of placing extra pairs of digits, which signify
placement of the individual in the household.
• These digits are usually placed immediately before the regularly assigned
number.
• Prefix number pairs have a definite sequence and meaning. All patient
information on one family is thus filed together by the family number.
41. Missing records
• Despite the extensive measures adopted to have good control of records, a
certain percentage of records are not found where they are supposed to be.
• This could be due to not receiving the file, not filing in appropriate place, or
misfiling.
• Under these circumstances, when a doctor insists on obtaining the original
record for rendering care, the medical records technician must create a duplicate
record with a similar number and with all previous ID data.
• The medical record technician should retain the duplicate record and
immediately trace out the original records and incorporate the forms of the
duplicate record into the original record. The record should then be filed.
42. Patient having multiple records
• As a general rule, each patient should have one record and one number. Due to
improper system or negligence of the hospital staff, the patients may have more
than one record.
• In that situation, it becomes necessary to retain one record by canceling the
others. The appropriate procedure is to retain the new record. The remaining
records have to be cancelled and given cross-reference numbers.
• All the documents in the cancelled records need to be moved into the retained
record.
• The cancelled empty folders with the cross-reference numbers should be
placed in their respective area. Any cancelled record number should never be
allocated to a new patient.
43. HOW LONG TO KEEP THE RECORDS?
Maintain health records in a standard proforma for 3 years from
commencement of treatment, according to Indian Medical Council
(Professional conduct, Etiquette and Ethics) Regulations, 2002.
21 year for neonatal patient (3yr + 18 year).
For children 18 year of age + 3 year.
For mentally retarded patient forever till hospital/institution is
working.
44. Guidelines for destruction of health records
• Public notice of destroying the records in English news paper and in
one vernacular paper mentioning the specific date up to which
destruction will be sought.
• Give a time limit of 1 month for taking away records for those who
want the records with written consent.
• After 1 month destroy the records up to date specified.
45. Take Home Message
Thus there are 3 fundamental principles of documentation to be always kept in
mind by medical practitioners –
Record the risk-benefit analysis of important decisions in the clinical care of
the patient.
Make use of clinical judgment at critical decision points.
The last principle of documentation relates to the patient’s capacity to
participate in his or her own care.
(Ref- Thomas G. Gutheil, Fundamentals of Medical Record Documentation, 2004 Nov; 1(3): 26–28.)
46. REFERENCE
1. https://jme.bmj.com/content/26/6/447 (8/4/2020)
2. https://cis-india.org/internet-governance/blog/privacy-healthcare.pdf (8/4/2020)
3. Mathioudakis A, Rousalova I, Gagnat AA, Saad N, Hardavella G. How to keep good clinical
records. Breathe. 2016 Dec;12(4):369–73.
4. Departmental Accounting: Meaning, Objectives, Methods, and Advantages [Internet]. ilearnlot.
2018 [cited 2020 Apr 4]. Available from: https://www.ilearnlot.com/departmental-accounting-
meaning-objectives-methods-and-advantages/58142/
5. Bali A, Bali D, Iyer N, Iyer M. Management of Medical Records: Facts and Figures for
Surgeons. J Maxillofac Oral Surg. 2011 Sep;10(3):199–202.
6. Physiopedia
7. APTA guidles for maintaing good clinical records.
8. http://clinicalestablishments.gov.in/WriteReadData/597.pdf
9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2779959/
10. https://www.wcpt.org/sites/wcpt.org/files/files/PS_Informed_consent_Sept2011.pdf
11. https://www.semanticscholar.org/paper/Medical-Record-Documentation%3A-The-Quality-of-
Phillips-Stiller/4e7ac89bfe20346a1a8d929923d790ac1a3b9037
12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4949052/
DOCUMENTS AND RECORDS GO HAND IN HAND AS DOCUMENTATION IS A PROCESS IN WHICH RECORDS ARE STORED ARE RETRRIVED WE HAVE EXPANDED OUR TOPIC AS DOCUMENATION