What sort of records should you keep?
- cleaning & maintenance
- safety procedures
- manufacturer’s warranties and guidelines
- personal credentials
- siigned informed consent, GAQ, etc.
- injury report forms
- client data
- SOAP notes
describe cleaning & maintenance records
- how often people clean the spaces, important if there’s an outbreak so you can easily track things
- show how you’ve been maintaining equipment and environment you’re in
describe safety procedures records
- EAP, policies, procedures, fire escape plan (fire plan and EAP posted so everyone can see them but any other safety procedures can be included in a binder on hand)
describe manufacturer’s warranties and guidelines records
- keep these so you can follow guidelines and ensure safety of equipment
describe personal credentials records
- ensure you’re staying up to date with professional certifications
describe signed informed consent, GAQ, etc. records
- at a confidential level, keep records
describe injury report forms records
- if there’s an adverse even, you need to fill out an injurt/incident report form, also keep confidential
describe client data records
*confidential
describe SOAP notes
- type of note taking taht summarized info based on meetings/assessment you had with client, used by many allied healhty professionals
- creates a SOAP note on every interaction with patient
which records are kept confidential?
- signed informed consent and GAQ
- injury report forms
- client data
- SOAP notes
*could be help liable, very important
how should client records be kept?
- well-organized & keep records of your client’s history, assessment results, training programs and progress
- records must be kept in a secure environment and as long as deemed necessary by provincial legislation (in Ontario this is 10 years/10 yrs after they turn 18, if you die someone else has to keep it for 10)
- all info containing personal info should be kept in password-protected files if on a computer or in locked cabinets if on hard copy
describe SOAP notes in more detail
- a method of summarizing a session with a client common amongst physicians and other allied health professionals
- used in addition to the client Information Sheet and other paperwork
- 1-2 pages summarizing subjective questions you’ve asked, your assessment, where plan of action will go
- can quickly look over before client visits
*used in a lot of professions
what do SOAP notes stand for?
S - subjective data (gathinginfo from client that is based on their opinion/responses)
O - objective data (data you’ve collected on client like height, weight, vo2max, etc *NOT EVERY MEASURE but highlight any abnormalities or things that require attention, usually anthro, CV, aerobic fitness, MSK)
A - Assessment of problem (think about objective and subjective data, and make an educated statement on what you think the results are)
P - Plan of action (briefly summarize what you plant to do in terms of working with client, not writing out entire prescription but using key strategies to improve some areas/goals of interest)
describe professional development as it pertains to CSEP CPTs
*allied health professionals have requirement to stay on top of new information, have to get a certain amount of PD credits
- stay on current literature (CSEP, ACSM position stands and PubMed)
- attend conferences (CSEP, ACSM, etc)
- educate through websites
