Table of Contents Table of Contents
Previous Page  22 / 96 Next Page
Information
Show Menu
Previous Page 22 / 96 Next Page
Page Background

22

physiotherapy.asn.au

QUALITY

consent before assessing and treating our

client. Seeking our client’s consent meets our

ethical and legal obligations and respects our

clients’ rights. Valid consent may be defined

as consent that is informed, freely given and

without duress, given by someone who is

legally and cognitively capable of consenting,

specific and covers the intervention or

procedure to be performed.

Informed consent is a person’s (or carer’s)

agreement to allow something to happen

to them based on full disclosure of risk,

benefits, alternatives and consequences

of refusal. Inherent to this is that a

conversation about the specific procedure

et cetera has taken place and our client

is able to make decisions based on this

information. Purpose-specific resources

often support our client’s understanding

of the issues related to consent and are

readily available.

SOAP

Key inclusions:

informed consent, clinical flags, precautions, warnings

provided and risk mitigation actions if appropriate

Subjective Interview for history, past/current biopsychosocial factors, physical

symptom profile

Objective Physical assessment and functional capabilities, tools/techniques, normal

and varied findings

Assessment Analysis:

•  overall clinical impression/diagnosis and options for remediation

•  outcome measures (SMART goals, clinical and patient reported measures)

Action:

•  intervention plan or action to address goals

•  treatment (techniques, equipment, exercise, dose, frequency, education,

self-management)

Response to treatment and relevant measures compared to baseline

Plan

Evaluation: evaluate treatment and progress made towards goals where

relevant

Monitor: indicators (eg when, how, what is monitored)

Discharge: information when clinically appropriate

Writing clinical notes to capture each of

clients’ varied stories is an integral part of

everyday practice and keeps our clients

safe through reflective reasoning. We all

want a locum or a colleague to be able to

understand our client’s story and we want to

meet the accountabilities that arise. The trick

to writing good content is knowing what the

key inclusions are and demonstrating how

we are responsible for our professional,

safe and effective practice.

It can be tough prioritising our daily tasks

and, most importantly, our client’s needs.

As a communication tool, respecting clinical

notes as important safeguards demonstrates

to third parties that we are good stewards of

funders’ resources and treat our clients with

respect, protect them from harm, act fairly

and are effective in our practice. While many

physios are writing good notes, at times

this can vary in both quality and content.

This is especially true when it comes to

documenting group and class interventions.

The APA is currently finalising peer-

reviewed, comprehensive guidance for

writing clinical notes. Current guidance

is very general and mostly developed by

external stakeholders, and our members

have asked for more specific and consistent

guidance which supports clinical reasoning

and our own regulation of good content.

This guidance aims to provide support

for our members who have questions

about what to do within legal and ethical

domains. Our members will benefit from the

associated tips and tools to help them write

good notes in a reliable way.

Good notes: good practice

CLINICAL NOTES

Scott Willis, APAM, Chair of Physiotherapy Business Australia, explains the importance of writing

high-quality clinical notes and provides some guidance for best practice.

Our intent is to express the guidance in

ways that ensure that it is illustrative and

descriptive, rather than prescriptive. The

guidance also supports the practice of

regulating note content through our own

reflection as well as peer review. This

type of regulation builds real trust and

commitment to safe and quality practice

rather than meeting prescriptive guidelines

developed by external authorities. We

anticipate that members can access the

guidance in a number of ways, from short

case examples and tools to the more

comprehensive background document.

For more information, email policy@

physiotherapy.com.au

.

Of the areas that members feel they need

support with, two of these are informed

consent and using a clinical reasoning

framework such as SOAP. In most

healthcare settings, physiotherapists seek