The Chartered Society of Physiotherapy The Chartered Society of Physiotherapy

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Audit tool: Communication

Details for quality assurance in communication can be found below. Please download the audit tool from the bottom of the page.

Part 1A: Data collection from patient records

There is evidence that

  • Members communicate openly and honestly with service users and consider the wishes of those who do not want themselves or other’s e.g. a relative to know the diagnosis
  • Members assess the recipient’s understanding of the information given
  • Members use active listening skills, providing opportunities for the service user to communicate effectively
  • The service user is aware of the role of any other member of the physiotherapy team, allied health professional, or social services staff involved in their care
  • All communication, written and oral, is clear, unambiguous and modified, where appropriate, to meet the needs of the service user
  • Methods of communication are modified to meet the needs of the service user e.g. where there is a language barrier an interpreter is used
  • Information is available on condition-specific support groups and networks
  • Where written information is provided to service users

a. a copy or reference is kept in the service user’s recordb. all information provided identifies the author, production date and review datec. superseded versions of information documents for service users are retained for the same length of time as health records

  • A copy or reference to written information to service users is kept in the service user’s record 

There is evidence that members

  • are aware of the roles of members of the multidisciplinary team
  • provide information for multidisciplinary assessments, planned transfers and discharges
  • ensure that the information supplied to other professionals is directly relevant to their role with the service user
  • communicate with other health professionals and agencies involved in the service user’s care
  • communicate relevant information clearly and promptly
  • agree common goals with the service user, multidisciplinary team and wider carers and family
  • when delegating a task, ensure that the line of responsibility is understood and clear
  • ensure that where a task has been delegated, the outcome is clearly communicated 

There is evidence that members ensure that

  • there is privacy when discussing personal details e.g. communication of a sensitive nature
  • service user identifiable information is transmitted securely
  • service user’s information is only released to sources, other than those immediately involved in the plan for intervention, with permission or when there is a signed consent form to allow this process
  • the written consent of service users is obtained before using identifiable clinical information (photographs, videos etc) for purposes other than the treatment of the patient
  • where confidentiality cannot be guaranteed, the service user is informed of this fact and given the option to decline giving information
  • when it is of benefit to the service user and in discussion with the service user, other healthcare workers may be given access to the physiotherapy record
  • consent is sought from the service user before discussing confidential details with carers, friends or relatives

Part 1B: Data collection from organisational policies and procedures

  • There is an organisational chart available

There are policies or procedures including

  • Locally agreed systems for referral
  • Locally agreed processes for the provision of information for multidisciplinary assessments, planned transfers and discharges
  • Policies which govern the use of electronic communication to ensure it is appropriate, secure and confidential
  • Policies for the use of social media professionally, socially and responsibly
  • Information available on condition-specific support groups and networks
  • A copy or reference to written information to service users is kept in the service user’s record
  • All written information for service users identifies the author, production date and review date
  • Superseded versions of information documents for service users are retained for the same length of time as health records 

There are organisational policies in place for the

  • Referral and transfer of care
  • Use of electronic communication to ensure appropriate information is conveyed and that such communications are secure and confidential
  • Delegation of treatment to outside agencies
  • Use of multi-professional record keeping and service user-held records 

There are procedures in place to ensure that members

  • Are aware of lines of communication within and outside the organisation
  • Inform others of their own specific role
  • Are involved in regular team meetings/ briefings
  • Are represented at organisation-wide meetings where these exist
  • Are involved in senior management policymaking and the business planning process
  • Are aware of the roles of members of the multidisciplinary team
  • Provide information for multidisciplinary assessments, planned transfers and discharges
  • Ensure that the information supplied to other professionals is directly relevant to their role with the service user
  • Communicate with other health professionals and agencies involved in the service user’s care
  • Communicate relevant information clearly and promptly
  • Agree common goals with the service user, multidisciplinary team and wider carers and family
  • When delegating a task, ensure that the line of responsibility is understood and clear
  • Where a task has been delegated, the outcome is clearly communicated 

There are procedures in place to enable members to

  • Ensure privacy when discussing personal details e.g. communication of a sensitive nature
  • Securely transmit service user identifiable information is transmitted securely
  • Release service user’s information only released to sources, other than those immediately involved in the plan for intervention, with permission or when there is a signed consent form to allow this process
  • Obtain the written consent of service users before using identifiable clinical information (photographs, videos etc) for purposes other than the treatment of the patient
  • Inform the service user where confidentiality cannot be guaranteed and give them the option to decline giving information
  • Provide other healthcare workers access to the physiotherapy record when it is of benefit to the service user and in discussion with the service user
  • Seek consent from the service user before discussing confidential details with carers, friends or relatives 

There are policies in place, which are followed to

  • Ensure the confidentiality of service user identifiable data held, or transmitted, in electronic formats
  • Ensure the confidentiality of service user identifiable data seen by members but intended for other professional team members

Part 2: Service user feedback

  • I felt that the physiotherapy team listened to me
  • I was able to discuss my care
  • I was aware of the roles of members of the physiotherapy team and others involved in my care
  • Information given to me was clear and easy to understand
  • Information was available on support groups and networks for my condition-specific

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