Actions | Yes | No |
I keep a separate record for each client. | | |
I obtain and record informed consent for all services provided. | | |
My entries are legible, accurate, and made in chronological order and clearly dated. Any corrections I make to records do not remove the original information. | | |
I have signed my notes, and initialled any corrections or additions. | | |
I record sufficient information to allow me or someone else to return to the records at any time and be able to understand what took place and why. | | |
My entries are made at the time of the session, or as soon thereafter as practicable within 48 hours. | | |
If I don’t have an opportunity to write my notes until the following day, I always enter the date I’m making the additional entry in the client’s record. | | |
If documents are scanned to the record, such as external reports, the scanning is done to a sufficient quality that retains the legibility of the original document. | | |
I have consistent processes for recording the details of any further interactions with clients that may occur via telephone, text message or other method. | | |
I only use abbreviations that are widely recognised and accepted in speech pathology or I provide a list of abbreviations in the client’s file. | | |
I don't make subjective or emotive comments; all information is professional. I know that clients have a right to access their records. | | |
All client care and entries in the record are made with the SPA’s Code of Ethics in mind. | | |
I keep an appropriate, consistent standard of clinical records for all clients, not just those with complex needs. | | |
While I may ask a suitably qualified assistant to record some health information in the client’s record, I always review their entries. I know that I cannot delegate responsibility for the accuracy of health information recorded to another person. | | |
The date of any funding claim matches the date of therapy in the clinical record. | | |
The claim item number matches the therapy type and length detailed in the clinical record | | |
The provider number recorded for a claim matches the provider number for the speech pathologist that provided the service according to the clinical record. | | |
My records are stored securely and in a way that ensures they can be promptly retrieved | | |
My records are collected, maintained, transferred and disposed of in accordance with privacy laws and state or territory laws. | | |
I have developed a privacy policy that provides information to clients about the collection, access, disclosure and retention of their health records. | | |
We have regular training for everyone at our practice about the appropriate collection, storage, access and disposal of records. | | |