Applied practice and procedures
Domain 3: Applied practice and procedures
This domain tests whether you can follow an IROP process from first contact to closure, with records that another person could audit. Expect scenario questions on intake, assessment, planning, delivery, referral, documentation, and review.
Process controls
- Verify identity and authority before disclosing or acting. Record what was checked, when, and by whom.
- Assess need against defined criteria, then plan with measurable objectives and agreed responsibilities.
- Obtain and record consent or another lawful basis before the activity, not after.
- Document contemporaneously. If a record is completed late, label it as a late entry and explain the delay.
- Escalate when findings exceed your competence, authority, or resources. Referral is a controlled handover, not a discharge.
- Close with review: outcomes, unresolved risks, follow-up owner, and date.
Worked example
A practitioner realises after a session that an allergy was mentioned but not recorded. The correct action is to add a dated, signed addendum stating what was disclosed, when, and the source, then notify the responsible clinician and update the risk plan. Overwriting the original note or backdating the entry destroys the audit trail and misrepresents the sequence of events. Reasoning: the record must show both the original omission and the correction.
Traps
- Documenting before the activity to save time.
- Copying forward previous notes without verifying current status.
- Acting on a verbal instruction without recording who gave it and their authority.
- Treating referral as closure without confirming receipt.
- Deleting or overwriting an error instead of correcting by addendum.