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ISSN 0031 9406 October 1998 Volume 84, No 10

Journal of The Chartered Society of Physiotherapy

CSP telephone 0171 306 6666

Journal telephone 0171 306 6662 Journal fax 0171 306 6667

HOW GOOD IS YOUR DOCUMENTATION? Good documentation for the rehabilitation of older people who have fallen is urgently needed in England and Wales! How much is available in other specialist areas of physiotherapy and occupational therapy? Although the approach of a national audit has stimulated preparation of this leading article, many of the recommendations made may be helpful to specialists in other areas of rehabilitation.

Good documentation in this case is taken to mean local policy statements, guidelines, protocols, checklists, patient records and other printed material that facilitate assessment and choice of rehabilitative intervention for a particular clinical problem and promote a consistent high level of practice and teaching. Preferably the content will be in accordance with currently accepted, where possible evidence-based, good practice.

Earlier this year a survey alerted physiotherapists and occupational therapists in elder rehabilitation to the forthcoming national audit of the implementation of the Guidelines for the Collaborative Rehabilitative Management of Elderly People who have Fallen (Simpson et al, 1998; Dowling, 1998). The results of this survey showed that jus t over 20% of the 688 services who responded use specific programmes or interventions to manage these clients. Of these, 11 responded to the invitation to send in copies of their documentation.

The quality of the material submitted ranged from hand-written notes of what a service claims to offer, some jotted on the back

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of the questionnaire itself, t o A4 spiral-bound booklets detailing full programmes of assessment and intervention. Many of the documents, such as general assessment checklists and general fitness programmes for elderly patients, were not specific to the rehabilitative management of those who have fallen. The remarks that follow relate to occupational therapists as well as physio- therapists.

Write It Down! Print It Out! If it not written down, however innovative and comprehensive your assessment and intervention programmes may be in your head, in practice they do not exist! Furthermore you cannot share them with your colleagues or use them in student training and assessment.

Services in which local management protocols are not being developed and reviewed will risk variation in practice between therapists within that service.

Moreover, checklists for assessment and man- agement do not preclude writing clear SOAP notes, while graphs and other quick and easy forms of measurement notation save time when regularly recording patients’ responses to intervention.

Own Your Documentation! A few respondents might have cut off identifying headings from their documents, but clearly in many cases there were none to cut off. All documentation should be printed on paper with some sort of heading: the trust, department, title of the document - and logos look nice! The date of that version should also be appended. When appropriate it is a good idea to add the date of the next formal review, eg ‘To be reviewed in June 1999.’

Make Provision for the Answer To Be ‘No’ For example when patients indicate that they have not fallen recently, or in the last six months, or in the last two years or whatever, then this should be recorded in the notes. Or if a check- list is being used, ‘No ’ as well as ‘Yes’ should be an option t o be ticked, for example ‘Home hazard assessment carried out? Has the patient been examined by GP physician in connection with the (recent) fall? A space for comments is often useful.

Acknowledge the Work of Others If you use a standard scale, index or other assessment procedure, it is considered good practice to quote the source. Include the author’s name in the title when this is usually done, eg

‘Berg Balance Scale, Barthel Index’ - and cite the reference. This is particularly important if the scale has been modified - for example there are two versions of the Barthel Index.

Make It Clear Whether You Are Following Any Guidelines Once staff have decided to follow available guidelines for managing a specific client group or clinical problem, this decision becomes service policy, so printing a policy statement to that effect becomes appropriate. Alternatively, if the decision is made not to follow any guidelines but to adopt another scheme, then this should also be recorded.

At least half the respondents who submitted documentation appear to be following the Guidelines on falls management. About a dozen services have gone so far as to set standards for implementing the Guidelines, some more completely worked out than others.

Numerous checklists for assessing ability to withstand balance threats and home safety education leaflets have been received. A wide variety of objective measurements appear to be in use, some of them operating at the impair- ment level, tapping static and dynamic balance - and others, at the disability level, checking functional abilities and components of general mobility. Occasionally there was evidence that emotional aspects of postural instability were also being assessed.

A few centres sent in well-worked-out care pathways but it was rare to come across detailed guidance for individual intervention when balance problems were identified. The commonest form of intervention appears to be for patients to attend a ‘falls group’ of some kind. This name seems to have achieved wide acceptance but is it really the most appropriate title? If the aim of the ‘falls groups’ is to promote postural stability, balance confidence, safety at home or whatever then a title which reflects these positive aims might be more attractive.

Few protocols detailing recommended exercises were submitted.

A wide variety of patient-oriented educational material was sent in, for the most part dealing with safe behaviour at home. Some services use the well-known leaflets professionally produced by the Royal Society of the Prevention of Accidents and by Age Concern; others have produced their own, some very good indeed. Nevertheless, it was rarely clear how this material was used. Surprisingly, few checklists for home visits were submitted.

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Be Kind to Your Auditor! Good documentation should also facilitate good auditing of practice. During any such audit, the auditor looks for written evidence to check whether key elements of practice are carried out or not. In many cases the unfortunate auditor is required to plough through pages of variably organised treatment records in order to find out how each patient who fulfilled the criteria during the audit period was managed. How much easier i t is for a n auditor when the service team has thought about documentation needs with respect to this clinical problem and drawn up local guidelines supplemented by assessment checklists, intervention protocols, graphs and

I The National Collaborative Falls Audit will start at the end of October 1998 and will take place in NHS Trusts throughout England and Wales. In support of this, the November 1998 issue of Physiotherapy will feature further articles about clinical audit.

A leading article on the same subject by Dr Simpson is being published in the October 1998 issue of The British Journal of Occupational Therapy.

References tables to plot progress. It can be done! Dowling, K (1998). ‘Survey reveals lack of guidelines’,

Physiotherapy Frontline, 4, 10, 20.

Dowling, K (1 998). ’Elderly falls audit is launched’, Physiotherapy Frontline, 4, 18, 10. Simpson, J M, Harrington, R and Marsh, N (1 998). ‘Guidelines for managing falls among elderly people’, Physiotherapy, 84, 4,

Janet M SimpSon phD MCSP AFBP~S

representative, Audit Working Group Member, Audit Steering Group 173-177.

This feature outlines the principal contents of journals and newsletters of Specific Interest Groups. To obtain the publications please contact the honorary secretary of the appropriate group, published in the CSP Annual Report.

Association of Chartered Physiotherapists Interested in Neurology Synapse 1998 Spring Sensory assessment after stroke C Winward

In at the deep end: A clinician’s perspective on research A Reid

Belt with hanging cords as a walking aid in Huntingdon’s disease C Barker

Association of Chartered Physiotherapists in Sports Medicine Physiotherapy in Sport 1998, vol21, no 1, February Rugby Union injuries: Patterns and prevention N Powell Rugby players and weight training N Phillips Rugby Union football B Kenny

The effects of seasonal change in Rugby League L H Phillips

No2, June

L Booth Over-use injuries Fatigue and under-performance in athletes R Budgett Magnetic resonance imaging in over-use injuries W W Gibbon

Endofibrosis of the external iliac artery: A Taylor

Chronic or repetitive strain injuries (over-use injuries) T Crisp

on the incidence of injury

Is it just professional cyclists who suffer?

Organisation of Chartered Physiotherapists in Private Practice In Touch

1998, no 84, Winter Physiotherapy treatment of stress urinary

Acute low cervical root conditions:

incontinence J Laycock

Symptoms, symptom behaviour and physical screening L Gifford

The medico-legal minefield Aloe Vera: Myth or medicine?

No 86, Summer Massage: Use it or lose it

W Emberson P Atherton

E A Holey

Shoulder pain and myofascial trigger points An introduction to subjective examination

The Internet and your business Delighting the patient: A key element of

Plan for success Who’s afraid of the Millennium bug?

R J D’Souza G P Grieve

T Storr

your marketing approach C Swaffin-Smith L McCann, K Taylor

L Newton

British Association of Chartered’ Physiotherapists in Amputee Rehabilitation 1998, issue 8, Spring A post-discharge functional measure for

Risk assessment and management in prescription

The influence of prior stroke on the prosthetic

lower-limb amputees S Sickalingam

and delivery of lower limb prostheses I Al-Khawaja

rehabilitation of lower limb amputees V Neumann, D G H Cotter, J M L Geddes. R Waman

Physiotherapy, October 1998, vol84, no 10