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OA Webinar - Clinical record keeping, by Brian Nicholls (Audit trends…
Audit trends
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There is a direct correlation with consult times and record keeping quality - shorter consults = poorer record keeping
Increased issues with newer practitioners - they learn bad habits from other more experienced practitioners
When consent is needed
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New complaint - only relevant if deemed that there's new risks, e.g. a more complicated complaint that might need further studies
Change in ttt plan, e.g. ttt with higher risk - DN, cx HVLA
ttt of sensitive areas, e.g. buttocks, groin, chest
Adjunctive therapies, e.g. DN or exercise prescription
Storage, maintenance and transmission of pt info
Legally, records must be completed on the day of the treatment. Records completed at a later date are "alterations"
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Records need to be kept for 7 years after the last consult. Records of minors need to be kept until they're 25 YO
Record keeping
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Onset & progression, SQIRTN, thorough past med hx
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Consent issues
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Legally, consent is only achieved after examination, dx & ttt plan discussion are done with patient in person
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