Documentation

Efficient documentation of consultations is essential for maintaining high-quality healthcare. It involves detailed, structured, and timely record-keeping that not only ensures continuity of care but also facilitates compliance with Australian healthcare regulations and standards.

1. Clinical Software and Structured Templates:
   • Employing structured templates can streamline the documentation process.
     • SOAP is a popular framework
     • Hx Ex Ix DDx Mx FU is another framework
   • These templates help ensure that necessary information is captured accurately and systematically.
2. Concise and Relevant Notes:
   • It’s important to keep documentation concise and focused on clinically relevant information.
   • This helps in maintaining clarity and ensures that critical information is easily accessible for follow-up care, audits, and compliance checks.
3. Standardised Terminology and Abbreviations:
   • Using standardized medical abbreviations and terminology that are accepted within the Australian medical community can save time and minimize errors.
   • Abbreviations such as SOBOE (Short Of Breath On Exercise) FOOSH (Fall on outstretched hand) are appropriate
   • Abbreviations such as PFO (Pissed and Fell Over) and LOL NOD (Little Old Lady in No Obvious Distress) should not be used.
4. Use of My Health Record System:
   • This system allows healthcare providers to access and update patient health information securely, promoting better information sharing across different healthcare settings.
   • There is a Practice Incentive Payment (PIP) attached to the uploading of shared health summaries to the MyHR.
5. Compliance with Legal and Ethical Standards:
   • Notes should have a professional tone.
   • From time to time exactly what you have documented will be requested by the police, courts, insurance companies or another general practice.
   • Various MBS item numbers have various documentation requirements that must be present for a claim to be valid.
   • While MBS audits are relatively rare, if you do face an audit, your notes form a big part of your defence.
6. Ongoing Training and Professional Development:
   • All software systems have a learning curve, so onboarding can be important.
   • Continuous professional development and training ensure that all staff members are proficient and up-to-date.
7. Quality Assurance and Audits:
   • Periodic audits of medical records are recommended to ensure adherence to Australian healthcare standards.
   • Feedback from these audits can help identify areas for improvement and enhance overall documentation practices.

There are two common frameworks used to structure the documentation of a patient encounter.

SOAP

The SOAP template is a widely used method for documenting medical consultations and encounters. SOAP stands for Subjective, Objective, Assessment, and Plan. This structured format helps healthcare providers organize information in a clear, concise, and systematic way, facilitating efficient communication among healthcare teams. Here’s a breakdown of each component of the SOAP template:

1. Subjective (S):
   • This section captures everything the patient reports about their condition.
   • It includes the patient’s description of their symptoms, their duration, their severity, and any other personal perceptions related to their health issue.
   • This can also include relevant medical history, family history, and social history that affect the current complaint.
2. Objective (O):
   • This part details the findings from the clinician’s objective evaluation of the patient.
   • It includes physical examination results, vital signs (like blood pressure, temperature, pulse, respiration rate), laboratory results, imaging studies, and any other measurable data obtained during the evaluation.
3. Assessment (A):
   • In the assessment section, the healthcare provider synthesizes the subjective and objective information to make a clinical judgment.
   • This might include a diagnosis or a list of potential diagnoses (DDx).
   • It can also involve a discussion of differential diagnoses, where the clinician lists other possible conditions that might explain the patient’s symptoms.
4. Plan (P):
   • The plan section outlines the steps to be taken next.
   • This can include ordering further tests, referrals to specialists, treatment strategies (such as medications, therapy, or surgery), patient education, and follow-up appointments.
   • It also details any prescriptions given or changes to existing medications.

The SOAP note format is highly effective in both inpatient and outpatient settings. It ensures that all necessary aspects of a patient’s case are considered and documented in an organized manner. This not only enhances the quality of care by providing a comprehensive picture of each patient encounter but also improves communication between different healthcare providers who may be involved in a patient’s care. Additionally, SOAP notes are invaluable for legal documentation and billing purposes, as they provide a thorough record of all clinical interactions.

Hx Ex Ix DDx Mx FU

While this is more suited to Medical Registrars working in hospitals, a full medical history looks like this:

1. Hx – History:
   • The full form of medical history can be remembered with the mnemonic PRoMPF STOPI
     1. Presenting Complaint (PC)
     2. Review of Systems (RoS), including red flags
     3. Medication History (MHx), including compliance and allergies
     4. Past Medical History (PHx)
     5. Family History (FHx)
     6. Social History (SHx)
     7. Travel and Exposure History
     8. Obstetric/Gynecological History
     9. Psychiatric History
     10. Immunization and Preventive Care History
2. Ex – Examination:
   • This includes:
     • Basic observations such as T, P, BP, SaO2
     • A systematic check of the patient’s body using various techniques like inspection, palpation, percussion, and auscultation.
     • The results from this examination provide objective data about the patient’s condition, which are essential for forming a diagnosis.
3. Ix – Investigations:
   • Investigations (Ix) include any diagnostic tests ordered to further assess the patient’s condition.
   • These might include
     • Office tests such as BSL, Urine dipstick, ECG, Spirometry
     • Blood tests
     • Imaging studies (X-rays, Ultrasound, CT, MRI)
     • Biopsies
   • The choice of investigations typically depends on the initial findings from the history and physical examination.
4. Dx/DDx – Diagnosis/Differential Diagnosis:
   • If the diagnosis is unclear, this will sometimes be called “Imp”, standing for Impression.
5. Mx – Management (Plan):
   • Management (Mx) outlines the treatment plan devised based on the results of the history, examination, and investigations.
   • Non-pharmacological management, such as lifestyle modification, should be considered.
   • Using a tincture of time (wait and see) should be considered, as not all problems require active intervention.
   • Active management might include prescriptions for medication, referral to physiotherapy or surgery, etc.
   • Effective management is often a blend of immediate treatment actions and long-term health strategies.
6. FU – Follow-up:
   • This component addresses the scheduling of subsequent visits to monitor the patient’s progress, assess the effectiveness of the treatment, and make adjustments to the management plan as needed.
   • Follow-up also allows the patient to discuss any new symptoms or concerns that arise after treatment has commenced