Maintaining Records

CSP members should only use short forms (abbreviations) if:

• It sounds cool.

• There is an agreement with your band 6 physiotherapist.

• There is an agreed list developed locally that is accessible to anyone entering or viewing health information.

• You have seen the abbreviation used by a Consultant.

When you have made a written error in clinical notes you should

• Draw a straight line through your error.

• Sign your name next to your error.

• Date your error.

• All of these.

Clinical notes must be written how long after seeing a patient?

Note- ASAP is always best!

• 12 hours

• 24 hours

• 48 hours

• 6 hours

What does SOAP stand for when writing notes?

• Sub-assessment, Objective, Analysis and Plot.

• Subjective, Observation, Action Plan and Plot.

• Subjective, Objective, Analysis and Plan.

• Subjective, Objective, Activity and Plan.

How many identifiable pieces of information must be recorded on each page of a patient's notes?

• 1

• 2

• 3

• 4

When a physiotherapist is employed, the records/notes that they create belong to who?

• The physiotherapist

• The patient

• The employer

• The NHS

All clinical notes must be written in

• Dark ink

• Black ink

• Blue ink

• Invisible ink

The bottom of every other page should be signed

• True

• False

Which two documents do the HCPC set out the responsibilities that a physiotherapist has?

• Standards of conduct, performance and ethics

• Physiotherapy Guidance Policy 2018

• Guidance for Allied Health Professions

• Standards of proficiency: Physiotherapists

Which act regulates the use of information about living individuals in relation to obtaining, processing, using and disclosing information?

• Access to Health Records Act 1990

• The Access to Medical Reports Act 1988

• Data Protection Act 1998

• Freedom of Information Act 2000