Purpose:
To standardize the documentation process for Wheelchair Fitment service, ensuring that all relevant patient information is accurately recorded and easily accessible. By following this SOP, healthcare providers can ensure that patients receive timely and appropriate care, facilitate continuity of care, and support data collection for quality improvement initiatives. This SOP also aims to streamline workflows and reduce the risk of errors in patient records.
Follow the step for documenting Cervical Cancer Screening service in Outpatient:
Log in Outpatient.
Search for the patient file. You can search for the patient file using any of the following methods:
Visits - This shows you a list of all visits for the day. If patients are not checked out in the system, the visit automatically gets checked out after 24 hours.
All Visits - Here you can search for patients using Phone number or Evax ID only. It shows you patient visit history.
Recent Activity - This shows you a list of files that you have recently opened and the time you accessed the file.
Go to the visit screen and click the plus icon on services to add a Wheelchair Fitment service.
ASSESSMENT TAB
Background Section
Doctor's Note or Government Certificate - If patient got doctor's note or any other documentation from the government, click Yes, else, click No.
Narrow doorway at home - if the doorway is narrow that it might be difficult fitting a wheelchair, click Yes, else, click No.
User public transport - if the patient uses public transport when traveling, click Yes, else, click No.
Reason Needing Wheelchair - Enter the reason why you need wheelchair.
Medical Assessment Section
Assistance type - Select if patient needs assistance to get on the wheelchair.
Able to keep head up - Select Yes is patient is able to keep head up on his/her own.
Able To Keep Body Upright - Select Yes is patient is able to keep body upright on his/her own.
Able To Use Arms Legs - Select Yes is patient is able to use arms and legs on his/her own.
Able To Control Bowel/Bladder - Select Yes if patient is able to control the bowl/bladder. \
Need Lap Belt - Select Yes if patient needs a lap belt. This is used to secure patients on the seats by the laps.
Need Harness - Select Yes if patient needs a lap belt. This is used to secure patients on their seats.
Need Postural Support - Select Yes if patient needs a devices or techniques used to help maintain proper alignment and support of the body while sitting.
Need Pressure Cushion - Select Yes if patient needs a pressure cushion designed to reduce pressure points that can develop from prolonged periods of sitting.
History of Pressure Sores - Select Yes if patient has history of pressure sores which are caused by prolonged sitting.
Active Pressure Sores - Select Yes if patient currently has pressure sores caused by prolonged sitting.
Active Open Wound - Select Yes if patient currently has open wounds.
Support Needed to Sit Upright - Select Yes if patient needs support to sit upright.
Assessment Notes - write any notes of things observed during assessment.
FITMENT TAB
Measurement and Configuration Section
Wheelchair Model - Select the model of wheelchair to be given to the patient
Seat width - Each wheelchair has seat width size, .so select the one that best suits the patient.
Footrest Modifications Needed - If there is any modification needed on the wheelchair, select Yes then enter footrest modification details on the text box that shows below.
Seat Length - Select the seat length required.
Backrest Position - Select the Backrest position that suits the patient.
Consent Section
Ensure that the wheelchair recipient and witness have consented and signed for the wheelchair.
Verification Section
Verify all the details and click Yes.
SAFETY TAB
Fitment Checklist Section
Make sure you review the checklist and attend to every detail of it.
Click safety check box when you complete.
TRAINING
Make sure you go through every section and train the patient on how to use the wheelchair.
This includes pressure sore education, transfers, safety, mobility skills, maintenance procedures.
Click the check box below if user training has been completed.
PHOTOS
Take photos of the wheelchair given, patient on the wheelchair from the side and patient on the wheelchair from the front.
SERVICE PROVIDER
Click "Select Service provider" link, followed by clicking by clicking "Set As Me" to show your name as the service provider.
SERVICE REVIEW