The Importance of Record Keeping in Support Roles
The Quality Assurance Program has begun the third round of peer and practice assessments. To date, kinesiologists have generally performed well and have demonstrated the required knowledge, skill and judgement associated with their respective practice roles. One area where some kinesiologists have experienced challenges relates to documenting in the patient/client record when working under the supervision of another regulated health professional.
It’s important to remember that if you work in a support role, you are accountable for the treatment you provide, even if it is prescribed by another regulated health professional. You are also accountable for your professional interactions with a patient/client and for documenting those interactions during the course of treatment. For example, you must record that the patient/client’s condition has been reviewed and note any changes, recommendations and rationale, and interpretation of re-assessments since the supervising health professional’s initial assessment. Here are a few points to consider when practising in a support role that will help you in your record keeping:
As a regulated health professional, you are always accountable for your own practice, regardless of whether you are in a support role. The Essential Competencies of Practice for Kinesiologists in Ontario, and the Standards of Practice and Practice Guidelines describe what is expected of you as a registered kinesiologist. You are expected to think critically about what you are doing and why, consider and respond to new information, and provide care in a competent, safe and ethical manner. For example, a kinesiologist working under the supervision of a physiotherapist is responsible for:
- ensuring that s/he has reviewed a patient/client’s assessment,
- acknowledging whether or not the physiotherapist’s assessment is still valid,
- confirming whether or not the patient/client’s condition has changed, and
- maintaining records accordingly.
Regardless of the level of autonomy in your position, you have a right and a duty to provide care that you believe is in the best interest of the patient/client.
Documenting as part of a team
If you work in a multi-disciplinary team, you are responsible for all aspects of the care provided and for completing integrated record keeping. The involvement of other care providers must be communicated to the patient/client, consent for subsequent changes to the treatment plan/intervention obtained, and notes made in the patient/client record.
Records serve as a memory recall for kinesiologists about their patients/clients. Working in a multi- disciplinary team creates multiple, and often overlapping, spheres of accountability. However, both the supervising practitioner and the kinesiologist in the support role are accountable for ensuring that the care assigned is safe, ethical and effective. Proper record keeping will protect you and helps demonstrate that you are providing the best possible care.
If you are a part of a multi-disciplinary team, you are able to review and analyze other health professionals’ information and to document in the patient/client record. You should ensure that other health professionals on the team are aware that you are regulated, and of your duties and responsibilities to practice standards pertaining to assessment/treatment, inter-professional collaboration and record keeping.
No matter the role or job title, you must maintain thorough documentation. Record keeping protects the patient/client and the kinesiologist. Records provide details regarding a patient’s/client’s progress, determine future care needs and ensure accountability for the care provided. Documentation is critical in enabling continuity of care for patients/clients from other treating health professionals.
See the right-hand side of this page for helpful resources.