All Wales Speech And Language Therapy Managers Committee
Pwyllgor Rheolwyr Therapi Iaith A Lleferydd Cymru Gyfan
Case note
Guidelines
For
Adult SLT Staff
Amended 6th June 2012
Ratified By:
Date of Issue:
Signature:
Date of
Review:
Page 1 of 7
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Guideline
No:
7
INTRODUCTION
This paper sets out guidelines and standards for case note keeping within
Speech and Language Therapy and has been ratified by the All Wales Speech
and Language Therapy Managers Committee. It draws heavily on the Royal
College of Speech and Language Therapists guidelines and Code of
Professional Conduct.
The guidelines have been prepared by the Adult Services Committee and are
for the use of all speech and language therapy services across Wales. They
are not intended to replace Trust policies but do allow for common standards
which can then be monitored on an All Wales basis.
The All Wales Speech and Language Therapy Managers Committee intends
this guidance to allow each service to have clear standards of case note
keeping in line with the Data Protection Act (1998) and RCSLT guidance that
can be audited on a regular basis.
Evidence indicates that inadequate and inappropriate record keeping can
neglect the interest of clients through:
a) Impairing the continuity of care;
b) Impairing communication between staff;
c) Failing to focus attention on early signs of deviation from the norm;
d) Failing to place on record significant observations and conclusions.
PURPOSE
Case notes are necessary to ensure continuity of care; client safety;
communication with colleagues; evidence of practice and as a legal
requirement. A record is required for every client and it is to be managed by
the appropriate speech and language therapist.
The function of case notes is to:
1) Provide accurate, current, comprehensive and concise information
concerning the condition and care of the client, source of and reason for
referral;
2) Provide a record of any problems that arise and the action taken in
response to them.
3) Provide evidence of care required; intervention by practitioners; and the
client responses.
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4) Record the chronology of events and the reasons for any decisions
made.
5) Provide a baseline record against which change can be judged.
6) Act as a tool for reflection on practice and evaluating and auditing its
effectiveness.
7) Act as a legal record of care, enabling the rationale for decisions to be
identified even after long periods of time.
8) Aid communications with other professionals.
STANDARDS FOR CASE NOTES – KEY FEATURES
Properly made and maintained records will:
1) Be made as soon as possible after the events to which they relate;
2) Identify factors which jeopardise standards or place the client at risk;
3) Provide evidence of need, in specific cases, for practitioners with
specialist knowledge and skills;
4) Provide details of other profession/agency involvement;
5) Aid client involvement in their own care and demonstrate that issues
surrounding confidentiality have been reviewed and appropriate records
made;
6) Provide protection for staff against any future complaint;
7) Wherever possible, be written in terms which the client will be able to
understand;
8) The originator will ensure that entries are accurate and factual.
The best practice principles of recording information are:
1)
2)
3)
4)
5)
Legibility
Timeliness
Accuracy
Completeness
Provision of an audit trail
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AUDIT/MONITORING (QUALITY CONTROL)
It is essential to ensure that records are completed and stored in such a way
as to facilitate the best interests of the client and enabling the provision of
care and the promotion of health.
They should also be kept in such a manner as to facilitate audit, the
investigation of complaints and the monitoring of quality standards.
The Guidelines for staff re: case notes audit sheet (see appendix 1) should be
completed by staff as part of the audit process.
REFERENCES
Department of Health (1990) Access to Health Records Act (1990) A Guide for
the NHS, Government Health Departments London, HMSO
Royal College of Speech and Language Therapists (2006) Communicating
Quality 3.
Royal college of Physicians (2007) Generic medical record-keeping standards
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ADULT SPEECH AND LANGUAGE THERAPY
CASE-NOTE STANDARDS-AUDIT FORM
Patient’s Name: _____________________________________ DOB: ____/____/____
Treatment Location: ______________________________________ Date Checked:
____/____/___
Name of Therapist:
(method of audit to be decided locally)
Date of feedback to therapist: ____/____/___
Standard
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Clearly written and legible.
Up-to-date. Contemporaneous, Written within 24
hours.
Black ink.
Each entry signed.
Full name and designation legibly printed against
signature.
Method of identification of signatories and roles
evident on front sheet.
Where entries are made by a Speech and
Language Therapy Assistant/support worker or
Student, on behalf of therapist – this must be
indicated, signed and counter-signed by
supervising therapist.
Errors are crossed out with a single line and
signed and dated.
Evidence of consent gained and documented on
each intervention.
Client’s language of choice recorded on front
sheet
P Number is recorded on front sheet
Patient or NOK phone number included
GP is included on front cover
If abbreviations used are not included on the
abbreviation list, write in full with the
abbreviation along side it.
Medical diagnosis is included on front cover
S&LT diagnosis has been clearly recorded on
front cover
CT Scan results dated and recorded in relevant
section of case history form
Date of admission of inpatients is included inside
as marked/date of referral clearly documented.
Reason for admission is documented and
presenting condition on admission
Impression Diagnosis is documented in notes as
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/ x
Comments
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appropriate. (This may change following
investigations or time and should be altered
accordingly)
Past medical History is documented.
Notes are in chronological order
Each sheet is numbered
Each continuation sheet/assessment sheet
contains client’s full name and NHS number.
Gaps in notes scored through and initialed
Clear notes about past therapy/treatment given.
Discussions (direct or indirect) with relatives/Dr’s
etc are documented and dated and signed as
above.
The time of appointment/assessment/telephone
contact is included for every intervention using
24 hour clock.
Each intervention states specifically if a
relative/carer was present during the session and
their name.
Indirect contacts are recorded and dated
A risk management form included in the notes if
relevant and a red triangle on the top left corner
of the notes indicates its presence.
Include relevant medications (or state that
medications are listed in medical notes) and
allergies recorded
ASSESSMENTS
Location where patient seen is documented eg.
IP, OP, HV
Relevant Assessments have been completed –
There is evidence in the notes of the rationale for
the choice of Assessment(s).
Assessments:
 results recorded
 clearly filled in and legible
 complete
 been analysed
 dated
The Assessments results have been fully and
appropriately discussed with patient / carer.
There is evidence of informal assessment, and
good interpretation of observations to support
decision making.
TREATMENT
The aims and objectives of the current treatment
are clear ie. Plan and recommendations are stated
at end of entry.
The aims/goal and objectives of the current
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treatment are clearly documented. (i.e; a therapy
plan is included)
The future needs of the patient are indicated in
plan
Treatment has been discussed with patient / carer
There are progress / up-date reports written
These reports:
 are timely
 are clear
 have been circulated
 details or a copy are in the notes
 (If a standard letter has been sent this info
has been documented e.g. letter sent, to
whom, on what date?)
All inward correspondence been acknowledged in
notes
Outcome measures are recorded.
If discharged, a summary in the notes or a report
has been written.
Reason for discharge is clear
All notes must be stored in locked filing cabinets
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