Computers in a treatment room?

Patients are used to seeing computers when they visit their doctor, dentist or physiotherapist. No longer considered taboo in the treatment room, on the contrary, computers are a very useful tool for documenting patient records. As with conventional note taking, care must be taken to be seen to be listening; full attention needs to be given to the person who is speaking. More detailed notes can be written whilst the patient is preparing for the treatment or between appointments.

The interactive consultation

The consultation is an essential part of the healing process. Patients appreciate the time and attention being paid to their problem. Physi-Cal is interactive and allows the patient to get involved in the documentation process. Rather than the therapist sitting there shuffling through paperwork and making unseen notes, the client can observe and openly collaborate in the procedure. The more patients understand and are involved the more comfortable they are likely to be with their treatment. Copies of the patients chart and treatment plan can easily be given or sent on to the patient if required.

Treatment Record Systems

A number of treatment record formats exist including SOAP and CARE notes. The system you use doesn’t need to be an acronym, you can adapt or develop your own format but it should satisfy certain minimum requirements. Download our free guide to record keeping (includes Treatment Record templates).

Why keep documentation?

  • Provides an examination and treatment history for each session.
  • Provides a record of contraindications and red flags.
  • Demonstrates and monitors patient progress.
  • Provides evidence to defend against a malpractice suit.
  • Records are required for reimbursement from insurance companies.
  • Records may need to be shared in the case of a referral.
  • Keeping treatment records may be required by law or code of practice.
  • Copies of treatment notes can be sent to patients.