In clinical practice, focus is always on the client’s presenting communication or swallowing disorder.
The assessment of developmental deficits, clinical signs, behavioural and play patterns, family dynamics and styles of interaction enables you to form a diagnosis and determines your therapeutic approach. There is an important feature of clinical management however, takes place when the client and family have left the room. This is documentation.
Documentation of past history, levels of developmental functioning, clinical presentation, family concerns and all other relevant information, forms the basis of your therapeutic plan and decision making.
Documentation;
- Assists in justifying the initiation and continuation of treatment.
- It describes patient progress.
- It shapes the short and long term goals, measures clinical outcomes, validating the therapeutic approach taken and records the clinical journey you take with your client.
- It justifies discharge from your care.
- It facilitates quality improvement.
- It provides data for research.
- It protects the legal interests among the involved parties, (practitioners, support staff, client and their caregivers, legally responsible parties and facility).
- It serves as evidence in a court of law.
It is a legal and professional requirement in all case management.
Laborious as this may be, when you are providing and conducting multiple sessions throughout your clinical day, it is essential that records are kept up to date with all relevant information recorded and then stored in a secure way with due consideration to privacy principles.
Events in the future may require this important information.
These notes proved invaluable, when several years ago, whilst providing expert evidence in the Supreme Court. Lawyers for opposing counsel, acting for the Insurance company of a severely head injured worker, attempted to reduce his future rehabilitation costs. They argued strongly to reduce the need for therapy and thus questioned the regularity and necessity of therapy and treatment.
Taking the stand and producing the detailed clinical history for the judge to hear, study and appreciate was personally satisfying and professionally rewarding. The client was in fact protected and his future rehabilitation and living costs assured.
Mr Craig Gorman
Speech Pathologist