Clinical Records Documentation and Management in Rehabilitation Therapy
Appropriate documenting and managing of client information to support clinical services
Type
Domain
Competency Area
Quality and Patient Safety
Levels
Document client information in compliance with policies and procedures
Identify and record clients’ clinical information on organisation’s templates in accordance with professional and organisational guidelines
Comply to legal requirements to safeguard clients’ data according to Personal Data Protection Act (PDPA)
Store and archive clinical records in accordance with professional and organisational guidelines
Manage client information in compliance with procedures.
Integrate clients’ current or latest clinical information with their permanent or supplementary records to ensure that list of functionally integrated records exist
Establish documented processes for recording, storing, archiving, and disposal of clinical records
Implement policies and/or guidelines for clinical record sharing to respect Personal Data Protection Act (PDPA)
Review documentation management done by junior staff according to clinical guidelines
Oversee and evaluate the clinical records management processes
Develop relevant documentation frameworks and templates to improve record management capabilities and support clinical decision-making
Develop policies and/or guidelines to promote client records integration and adoption of client records management according to best practices
Develop policies and/or guidelines to respect Personal Data Protection Act (PDPA) for clinical record sharing