Authors (including presenting author) :
WU IHL, AU MK, CHAN VWM, LEUNG MTC, WOO CW, CHAU RMW
Affiliation :
Physiotherapy Department, Kowloon Hospital
Introduction :
Comprehensive and throughout assessment is critical for identifying problems and forming of a tailor made treatment plan for patients. Heterogeneity in assessment content among staff affects the accuracy of clinical documentation and at risk of missing out essential information. To enhance high quality assessment and documentation, the guideline on Physiotherapy Documentation Template for Common Paediatric Conditions was approved by COC-grade in Physiotherapy and HAHO Allied Health Grade Office in April 2020. Developmental delay and torticollis, the two most common diagnosis among new cases in paediatric physiotherapy unit were included in this clinical audit.
Objectives :
This project aimed to identify the degree to which physiotherapists in paediatric physiotherapy outpatient unit in Kowloon Hospital adhered to the guideline on clinical assessment for developmental delay and torticollis conditions.
Methodology :
A retrospective review of patient record was conducted using audit forms. All patients’ record was included if the patients received their initial assessment during the sampling period from 1 June 2020 to 31 October 2020. Content on the assessment forms of torticollis and developmental delay condition were cross checked with criteria listed in the published guideline.
Result & Outcome :
A total of 47 patient records were included in this clinical audit. The majority of patients (93.6%) were diagnosed with developmental delay, while the rest (6.4%) were diagnosed with torticollis. The compliance of torticollis assessment was high, with 100% of records fulfilling all recommended assessment criteria. Information on clinical findings, interventions and recommendations for further management were all recorded in every torticollis assessment.
Among the records of developmental delay assessment, there were full compliance on the documentation of findings on subjective and objective assessment, sensori-motor and fine motor skills. In the category of ‘General outcome measures’, 95.7% of developmental delay assessment records contained an outcome measure result.
The findings from this audit suggested that clinical documentation are mostly in accordance with the guideline.
