Record keeping might be just an ordinary word for many, but it has massive importance in the social and health care departments. Keeping patient records is the ethical requirement of good social and health care and it has massive importance for clinicians and therapists.
This article will talk about the essentials of records and the importance of record keeping for clinicians and practitioners. And in the end, we will address some of the frequent questions that people might have about record keeping.
The Importance of Record Keeping for The Therapist
Record keeping is an important part of a therapist’s job because it helps the therapist to remember all the important information about the patient, as well as have that information in one place.
It has been proven that adequate patient record keeping enhances the quality of treatment. It helps practitioners see the patients’ circumstances and the problems they are facing. In short, it paints the whole picture so that the practitioner can figure out the best way to tackle the problem.
It can sometimes happen that the therapist forgets some details about their patients simply because they meet a large number of people during their sessions. The patients’ previous records help them remember the necessary details needed to have a successful session.
The Importance of Record Keeping for practitioners and clinicians
- Record keeping helps facilitate better communication with patients.
- It acts as the report of the previous treatment that helps maintain the continuity of the treatment.
- They ensure you have all the important information about the patient in one place.
- You can view the progress of your patient when looking back on old records.
There are a lot of benefits of writing patient records, we will see more about this in the next section of the article. For now, let’s talk a bit about the format of clinical notes.
The Best Format for Clinical Notes
The format of clinical notes entirely depends on you and how you want to design them. But to give you an idea of what would be good to include in the notes, we will share a format with you. Using this format might prove useful to those who are just starting and haven’t found the format that works for them yet.
- First of all, you need to mention the name of the patient, the date, and the context of the session.
- Afterward, if it is the first appointment with this patient write the patient’s medical history and other important background information.
- Then, write the details of services you have provided – the details of the appointment, test results, and similar.
- The next section should be your comment section. You can write your assumptions regarding your patient’s condition in this section. You can fill this in while talking to the patient or while your patient is answering your questions. Usually, it is better to note the main points on the spot and add the extra information later, it takes less time, and there are fewer chances of missing any important information
- In the next section, you should write any recommendations and solutions you give to the patient.
- Lastly, you write the date of the next meeting if required, and you put your signature at the end so it is clear that you have written them.
Extra tips for record keeping
- It is best to keep a patient’s information in one place, so keep plenty of space for future sessions. For this, it is recommended to be flexible while writing the patient record so that you can add future information in each section.
- You can also make a section to write the patient’s progress or to write the changes or improvements that either the patient or you have observed.
- It is best to maintain records in sufficient detail to allow a different practitioner to take over the treatment in case it is needed.
- Reasonable efforts should be made to protect against the misuse of records.
- You should also write the details of the telephone communication or any other conversations with your client, whether via messages, calls, or emails.
So to recap – there isn’t really one correct way to keep patient records. You can choose the format that suits you the best, but be flexible and accurate while writing the record.
Matters That Should Not Be Included in The Clinical Notes
- The therapists’ job is to provide care to their patients. Their best interest should be to ease the life of their patients. For this purpose, you need to add the most accurate information to the record and not add any irrelevant thing.
- Avoid adding any negative comments to the record. Negative comments should only be added if they can serve a therapeutic purpose. Don’t add sensitive information to the record.
- Your client might request to see their record, or it might be used for any legal purpose, keep that in mind before writing the patient’s record.
What Is the Best Way of Keeping the Records?
A lot of therapists prefer to maintain their records in diaries and create handwritten clinical notes while making sure to keep the records as confidential as possible. But handwritten clinical notes are not completely reliable. That is why most renowned therapists have started electronic record keeping due to its numerous benefits. Let’s discuss some of these attractive benefits of electronic record keeping.
What Are the Benefits of Electronic Record Keeping for Therapists?
- If you are a practitioner or a therapist, you know the struggle of managing the patient’s records and uploading them. But don’t worry – we will introduce you to an alternative method of record keeping.
- Electronic record keeping is a way that will ease this process for you. Such software is incredibly intuitive and easy to use. You don’t need to carry heavy files and diaries to see the patient’s records. You open the record with a few clicks and find all the needed data about your patient.
- Maintaining the patient’s privacy is the therapist’s duty. If you want to maintain the privacy of your patients, clinical notes software is a good choice. With all the data regulation going around, they usually have a strong focus on keeping the data safe.
- Find software that follows HIPAA and GDPR regulations.
- Needing login information and a password means that people who don’t have these credentials can’t reach your notes and patient data.
- Online clinical notes are more manageable because their formats are flexible, and they often allow you to design specific formats for yourself.
- Clinical notes software is made with the needs of therapists in mind, and it can serve very well in maintaining patient data.
Is Online Record Keeping Possible for A Therapist?
As you all know, the world has recently seen a pandemic, and during this time, we have seen that online systems have taken the place of physical practices in many cases. Clinicians and practitioners started providing online services more than ever before. Many therapists are now using online systems for their practice.
Here are some of the benefits of online record keeping;
- Online record keeping could be the all-in-one solution to all of your problems. You can use this software to record the patients’ data, schedule meetings, and prepare texts and emails.
- This software can help you to organize online meetings with your clients and notify you about the scheduled meetings of the day.
- There are several online records keeping software, and they have different features. It depends on what kind of software you want to choose for your practice. Overall, online record keeping can help you run your clinical practice a lot easier.
How To Choose Online Record keeping Software as A Therapist?
Choosing the right software for record keeping could be tricky, especially when many options are available. But to make this decision easy for you, we would like to tell you some features that you should look at before choosing any management software for yourself.
Know your requirements
It is essential to know your needs first before choosing any software. For instance, if you wish to use the software only for electronic record keeping, you shouldn’t buy expensive software with a bunch of other features that you will not use.
So, understand your requirements first, then correlate your needs with the software’s features and choose the software accordingly.
Choose a simple-to-use software.
If this is your first time using such software it is important that it is intuitive and easy to use. You don’t want to waste too much time trying to figure out how it all works. Simplicity, good guides, and good support should be something to look for!
If you are a therapist, you will receive a lot of messages from your clients. Perhaps you are working alone now, but your services can be expanded in the future. For this, you need to check the scalability of the software. Scalability is the software’s ability to grow and shrink to meet the user’s demands.
Check the quality
Before trusting any software, make sure to read the reviews of previous users. Read about the pros and cons of the software, the response speed, about the overall reputation of the software. If you choose cloud-based software, check who is running your application and how serious they are about safety.
Software is to make the life of therapists easier by managing their records and simplifying their day-to-day operations. If your software is not doing this efficiently, then why bother? Make sure to choose the software that is giving you the best value.
Read our other blog post if you are interested in learning more about how to choose the right appointment scheduling and record keeping software!
Who Should Get Access to The Online Record?
Nobody should get access to the patient’s data without the permission of the therapist and the patient. It’s a therapist’s duty to keep the patient records safe. If you make the notes manually, keeping the notes in a safe place and monitoring your working area with surveillance cameras would be good. Also, limit the movement of the staff to your working area, and allow only specific trusted persons to visit your room.
Sometimes families of patients also ask the therapist to provide them with the records of their loved ones. It happens in complicated situations, but the therapist must work for the patient’s best interest. If you think that sharing patients’ problems with the family will be helpful for the patients in any way, then go ahead; otherwise, avoid sharing your patient’s data. Likewise, if this is prohibited by the data regulations of the country you operate in, avoid it in all situations.
How Long Should You Keep the Patients’ Records as A Therapist?
Depending on the regulations, there are limits to how long you can keep the clients’ records. Sometimes clients can also request you to remove their records. For this purpose, do what you think is right.
Removing the record is also the duty of the therapist. Make sure to choose the right way to remove your data, so it might not fall into the wrong hands.
Record keeping is a crucial part of health and social care. As a therapist, it is an integral part of your profession. If you want to excel in your professional career as a therapist, then you need to excel in the art of writing records.
A well-managed and complete record talks about the professionalism of a therapist. Online record keeping software will help you complete your hectic work in minutes.
Q.1 Why is record keeping essential for a therapist?
Record keeping allows you to have all the patient information in one place and insures that you don’t forget any important details during their treatment.
Q.2 How do we keep patients’ records?
Writing is the best way to keep the patient’s record. You can make clinical notes in a diary or use record keeping software.
Q.3 What is the best way to protect a patient’s record in counseling?
Maintaining the secrecy of the patient’s record is an important duty of a therapist. Online record keeping software can help you protect your patient’s data.
Q.4 Should I buy the paid version of the software for recording the data as a therapist?
Both free and paid versions of record keeping software are available. Paid version software has some advanced features. Initially, we recommend using the free version. If you feel that it is not fulfilling your needs, you can shift to a paid version of the software.