Making critical decisions about patients isn’t an easy task but quality information can make a world of difference to a person’s experience. Lizzie Cernik explains
Access to a patient’s details can make a huge difference to their treatment and their experience according to Helen Harte, CSP professional adviser. She says: ‘While working in the rapid response team I was once called to see a multiple sclerosis patient with an acute chest infection. His oxygen levels were so low that he’d normally be admitted by emergency to A&E.
‘However, the community electronic personal records told me that his baseline was always quite low. After a discussion with the GP, we did a period of breathing exercises and chest clearance to get it back up to levels that were normal for him.’
Instead of rushing him into hospital, which would have been stressful for the patient, accessing the information meant he was able to stay and be treated in his own home, with personalised care.
Without these vital details, physiotherapists and other professionals are working with their hands tied behind their backs. Standard procedures have to be applied in all cases, which can lead to all sort of problems including unnecessary admissions and treatment, delayed diagnosis and other issues. In addition it can slow down access to the right care, while additional checks are made.
‘It’s vital that physiotherapists not only have access to that information from multi-disciplinary teams but are contributing to it on a regular basis as well,’ says the CSP’s health informatics lead, Euan McComiskie, who advises the Professional Record Standards Body (PRSB).
Shaping the future of care with information
In his previous role as a physiotherapist in the Rapid Elderly Assessment and Care Team (REACT) at St John’s Hospital, Livingston, Euan was able to see first-hand the benefits of using digital records. The team moved their records to a digital system shared by the hospital so they could access records for patients discharged to their team and have their information ready should one of their patients be admitted.
‘It really hit home when we had a call from an A&E consultant one morning thanking us for our comprehensive records on a patient who’d had a fall at home the night before,’ says Euan. ‘The patient was taken by ambulance to the hospital. With all x-rays clear and the patient wanting to go home with their family, the consultant could see that their mobility was at their normal level, understand about the care package already in place and make a request for our team to see her the next day in her house. The consultant was grateful for our records making his clinical decision easier, the social care team could act swiftly to put a slightly increased package of care in place on a temporary basis and the patient was happy to avoid an unnecessary admission. Record sharing helped everyone achieve a better outcome.’
To provide the very best quality care to those who need it, integration between different services is absolutely essential. Physiotherapists can’t be seen as a separate entity, and must engage with other health and care professionals to deliver the right care to patients at the right time. ‘If someone comes to us having experienced a fall, we need to understand the full picture,’ says Ann Murray, falls programme lead and physiotherapist for the Scottish Government’s Active and Independent Living Programme.
‘We need to be able to identify all of the physical, psychological, social, and environmental factors that may have contributed to the fall, and to plan and deliver effective, outcome-focussed care. An integrated approach that includes safe, appropriate and structured sharing of information is key to this. As well as improving outcomes, it improves the person’s care experience.’
Making this integration a reality for everyone involves ensuring that information can be shared properly between different services through digital systems. Having all this information available when it’s needed will enable professionals to make fully informed decisions about a person’s care, which will inevitably lead to better outcomes. ‘While some people might see standards as a compliance exercise, in reality it’s a crucial part of supporting information sharing and integral to good care,’ explains Euan. Through quality records, professionals can share information about a person’s health, including everything from life threatening allergies to medications, social history and mental health history.
Sarah Judge, EPR clinical strategist and physiotherapist for West Suffolk NHS Trust, says that accessing information from assessments, treatments and plans with physiotherapy and other colleagues is essential for providing a seamless service for patients: ‘It means we can reduce the duplication of assessments and enables our staff to make informed decisions about patient care. It is truly a game-changer when it comes to providing a timely, high quality service to all of our patients.’
The CSP has contributed to the development of PRSB’s standards for patient records, including the digital care and support plan, which was published last year. This outlines the information that needs to be shared while a person is receiving long-term care. Physiotherapists care for many people who have chronic and complex conditions, as well as those who are on the road to recovery following accidents. Joined up digital care plans are an essential tool for integrating with other services, which this standard enables. The relationship between professionals and patients is changing, and the patient voice is now more important than ever before, which is something that shared records can support.
‘It’s very important that physiotherapists recognise the role that digital information sharing can play, and begin to use standards in our day-to-day practice,’ says Euan. ‘Even if you don’t have digital systems in place yet, using the standards provided by the PRSB can support better care, by ensuring that the right information is being recorded.’
Benefits of using records standards in physiotherapy:
- Gain information from GPs, hospitals, social care and others
- Contribute information to be used by other professionals
- Provide personalised integrated care for patients often resulting in better outcomes
- Lizzie Cernik is communications officer at the Professional Record Standards Body
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