WEEK 4

1. WEEK 4 Documentation and Record Keeping

2. Types of documentation required in health provision • Business letters • Referral letters • Case notes/files • Genograms

3. If I’m good at health provision why should it matter how my documentation looks • Because the way a business letter looks immediately gives the reader their first impression even before they read it. The quality of the paper, letterhead design, the margins, spacing and more all have something to say about the organisation or business. • A weakness in any of these elements can detract from the effectiveness of the message, even though it is expertly written.

4. Letter writing Business Letters/ Referral Letters

5. Think before Writing Regardless of the urgency; take time to answer the questions • ‘Why am I writing?’ • ‘To whom am I writing?’ • ‘What, if any, action do I expect as a result of what I have written?’ • This will make it easier to draft more clearly and concisely.

6. Why am I writing? • Is it to give someone information? If so, what information? For what purpose? • Do I need information? If so, what information? For what purpose? • Is some action needed? If so, what action? For what purpose?

7. To Whom am I Writing? • Who will the reader(s) be? • What does (and doesn’t) the reader know about the situation? • What does the reader need to know? • What questions will the reader have in mind when reading my communication? • How is the reader likely to react? • What is my relationship to the reader?

8. Write simply, clearly and concisely • Once we know what we want to communicate, to whom and why, we can draft correspondence clearly, correctly and concisely using a simple style. • It is easily read and therefore is easily understood.

9. Dos and Don’ts in writing • Be concrete • State your facts or ideas directly • Use verbs in the active • Use concrete words. • Use short words, short sentences, and short paragraphs • Don’t use any more words than necessary • Don’t use euphemisms or implied messages • Don’t use emphasis in correspondence. • Don’t use needless adjectives and adverbs • Avoid anything which might offend the sensibilities of the readers. Do’s Don’ts

10. Referral Letters • Always have clients permission before disclosing information • After the Addressee line put client detail ie RE: JANE DOE. DOB 30.04.73 • Be clear and concise as to the purpose of the referral • Own your statements ‘In my opinion...’ etc • Do not make presumptions of required treatment, leave that to the referring agent.

11. Writing a Fax • Use the fax only when the communication needs immediate attention • Always use a cover page • In addition to the cover page, format the message in either a memo or business letter format. • Do not send documents in which the appearance is important. • Avoid dark areas such as graphics. It slows down transmission time and the recipient printed fax may be moist from the heavy application of ink. • Use simple, legible type for your fax. Arial, Courier and Times New Roman all transmit clearly. Use at least an 11-point in size. • Avoid handwritten notes. They often don't transmit well.

12. Memo’s • The memo is short for memorandum. • It is used for short reminders, quick announcements or concise pieces of information. • When using the memo format, don't communicate something of vital importance • No set format for memo’s – try To From Date RE:

13. Emails • Email (electronic mail) is becoming a far more popular choice in the interaction of communication between agencies. • Even though you may use email informally with friends and family do not allow that to flow through to your professional email correspondence.

14. Format: To is for the individuals the letter is directed to, cc for those you want to have a copy and bcc to those you want to have a copy but don't want people to know they are in the list. And do fill in the subject line. Begin the e-mail with the salutation. • Contents: As with the business letter, keep it brief. All the business letter essentials apply to the e-mail as well. • Links: If you are referring to a web site, do provide a link. • Don't use ALL CAPS: In the real world, all caps mean that you are stressing a point. However when online, all caps means that you are YELLING! Bold the word or put asterisks around it to stress the word, although we recommend that professional communication avoids all emphasis.

15. Don't get too informal: The tendency when it comes to e-mail is to write less formally, just remember, you are still writing a business letter only via e-mail. • Don't use emoticons and acronyms: There are two reasons for this, first, while many net-savvy users are familiar with it, there are still a lot of people who don't understand what the symbols mean. Secondly, you are still writing a business letter, emoticons and acronyms are just too informal. Imagine a letter that reads like this: WTG Imagine my =:O when I heard ur good news. IMHO you earned the promotion. ;-) • Do use the advice on business letter format above. Just because you are sending a letter via email does not mean that proper business letter format do not apply.

16. Practical Tips for letter writing • Consider the reader • Be concise and to the point • Be prompt • Check spelling and grammar • Write a draft if it’s very important • Use the correct format

17. Student Activity Correct the Sample Letter

18. Guidelines for Case Notes VERY IMPORTANT • Case notes are usually kept for 7 years • Case notes can be subpoenaed as supporting documentation in a court of law • Most policies relating to case notes or personal files allow the client to access or have a copy of information contained in their file as they choose.

19. Record the date, time, location and names of those present • Record the source of information (who said what) • Aim for accurate and objective reporting – avoid bias and judgement • Record facts rather than your opinions • Record the reasons why you made a decision • Omit any information that is unrelated to case management

20. Be concise • Use plain, everyday language • You should ensure that all case notes, records of interviews and reports you write are dated and signed and meet all other organisational requirements

21. S.O.A.P Principle of Case Recording • S. = Subjective or summary statement by the client. Usually, this is a direct quote. • O. = Objective data or information that matches the subjective statement. • A. = Assessment of the situation, the session, and the client, regardless of how obvious it might be based on the subjective and/or objective statements. • P. = Plan for future clinical work. Should reflect interventions specified in treatment plan including homework assignments. Reflect follow-up needed or completed.

22. S. = Summary Statement • Usually, this is a direct quote. The statement chosen should capture the theme of the session. 1. If adding your own explanatory information, place within brackets [ ] to make it clear that it is not a direct quote. • Example of session theme: “My neck aches, my forehead is tight and I just... well it could be stress....’ [unsure why headaches occur] 2. If client refers to someone else’s name, indicate that other person by initials. This makes it clear that the client is the focus, not the person the client is talking about. It also guards against any breeches in confidentiality. • Example of client using someone else’s name: “I spoke with T and she suggested that I come and see you even though Dr S said it’s probably not necessary’ 3. If the client didn’t attend the session or doesn’t speak at all, use a dash on the “S” line. • Example: S: ---

23. O. = Objective Data Descriptions may include body language and affect. • Example: Frowned a lot, squinted at light, head tilt to the left

24. A. = Assessment Regardless of how obvious it might be based on the subjective and/or objective statements. • Example: Has debilitating headaches • Example: Neck pain related to muscle deterioration • Example: Eye strain related to lack of _____________ in diet

25. P. = Plan Should reflect interventions specified in treatment plan including homework assignments. Reflect follow-up needed or completed. • Example: started on herbal therapy of 60 drops of _____ daily • Example: Began acupuncture in the T3 zone, stimulation through heat also required • Example: Massage therapy of the trapezius muscle • Example: Homework: to not lift heavy objects above chest height.

26. Student Activity Case Study and Notes using the SOAP Principles.

27. Genograms • A genogram is a graphic representation of a family tree that displays detailed data on relationships among individuals.  • Genograms were first developed in 1985. now used in a variety of fields; medicine, psychology, social work and education. • Genograms contain a wealth of information. Basic data such as the name, gender, date of birth, and date of death of each individual. • Additional data may include education, occupation, major life events, chronic illnesses & emotional and social relationships. • Some genograms also include information on disorders running in the family such as alcoholism, depression, diseases, alliances, and living situations.

28. Basic Symbols • Female (add age) • Male (add age) • Unknown Gender • Married • Defacto • Separated • Divorced

29. Health Symbols • Heart Disease • Breast Cancer • Diabetes • Depression

30. Student Activity Create your own genogram, including any health aspects.