National Association of Hospital Play Staff 

Guidelines for Professional Practice

 

Number 4
Documentation

 

Introduction

Two main types of documentation exist within the Health Service:

·        patient records

·        data collection

In order to comply with professional standards and clinical governance regulations, Hospital Play Specialists (HPS) should contribute to both.

The important activity of making and keeping records is an essential and integral part of patient care and, as such, should not be viewed as a distraction from it. Good record keeping is important because it:

Patient records

To facilitate patient management and satisfy legal requirements, it is recommended that every patient who receives play input has a record, which includes information associated with each episode of care.

Guidance: whilst records are generally hand written, patient records also include computer records, audiotape, emails, faxes, videotape, photographs and other electronic data.  Keeping records is an essential part of a Hospital Play Specialist’s duty of care to the patient.

1. Patient records should be commenced at the time of the initial contact.

2. Patient records should be written immediately after the contact with the Play Specialist or before the end of the day of the contact.

3. Patient records should be contemporaneous and should not be added to after the time of writing.  Any genuine omissions should be recorded at the time the omission is identified.

4. Patient records should be:

Guidance: in some circumstances, to be determined locally, it will also be important to record the time the play session took place. In these circumstances, the audit of the standards should include this.

 

 

5.         Patient records should be retained in accordance with existing Trust policies and current legislation.       

6.         Patient records should be stored in a secure place.

Guidance: this relates to the individual’s responsibility in relation to confidentiality.  It applies to all patient related information; written, computer records, audiotape, emails, faxes, videotape, photographs and other electronic media.

In a community setting, patient records should be taken with the Play Specialist and not left in an unoccupied vehicle. They should be returned to base at the end of the working day.

 

 

Arrangements must be made so that access to the records is available to other play staff and managers, when the HPS is off duty. Guidelines state that complaints must be responded to within a short time, and details of the play services provided for an individual child may be required, even if the HPS is on annual leave.

7.         Play Specialists should comply with local IT security policies, and the Data Protection Act.

8.         Play Specialists should adhere to the local policy if asked by the patient to view their patient record.       

Data Collection

Managers of play services in hospital or individual Play Specialists, if there is no manager, should keep a numerical record of activity within their department or ward. This provides:

 

This may take the form of a day book or a photocopied form filled out each day. Devise an abbreviation system to make this less time consuming. The following list provides examples of abbreviations that can be used. It is by no means exhaustive.

C          = Contact

P          = Play

TH        = Therapy/therapeutic play = One to one work with a child or a member of their family of a therapeutic nature.

PREP   = Preparation play = Structured play to explain treatment or a procedure.

SIB       = Siblings = Contact or play with siblings.

PSA     = Parent Support and Advice = An episode of active listening or direct advice re: play or behaviour

Method
 

  1. All members of the play team should understand the abbreviations and their definitions. Using a tick chart form should ensure simple and efficient data collection.
  2. Data should be collected in all areas where the HPS works. Forms should be designed to meet the differing needs of each area. An out patients clinic where the children engage in normal play activities may only require details of the age and numbers of children using the play service. However, on an isolation ward, the type of play provided will vary according to the individual patient’s needs and it will be useful to collect data, which reflects this.
  1. If a pre-admission visit /club is run by the play team, it is important that a record of attendance is kept.
  2. It is important to record the total number of patients who could potentially have used the play service i.e. all those on the ward or in the clinic, as a baseline by which to compare the other figures. For example, there were 30 children in the clinic and 20 (66%) used the play service.
  3. Remember that data should only be collected from the hours covered by a HPS, e.g. numbers of patients on the ward when s/he is on duty, not including days off.
  4. Each area is different. Comparisons should not be made between the numbers of patients using the play service in each location. However, data collected over a period of months or years in the same location can give useful insights.
  5. The data contained in these figures should be collated on a monthly basis. At the end of the financial year, these can be put into table and graph format and included in an annual report, which should be reviewed by the play staff and circulated to the management team.  
  6. Some units have designed forms, which include patient notes and numerical data. The rules for patient records described above should apply in this case.

 

Reference

Quality Management for Children- Play in Hospital, Play in Hospital Liaison Committee, 1990

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