Documentation

Question 1

Why document

Answer 1

1. Communicate with other treating therapists
2. Assistance with discharge planning
3. Reimbursement
4. Assistance with utilization review
5. Legal document regarding the course of therapy for a patient

Question 2

Record

Answer 2

Progress notes and referrals

- departmental statistics and records are example of admin records

Question 3

Referral

Answer 3

Signed prescription form

• must include name of patient and be signed and dated by referring physician
• sometimes include number and frequency of treatments desired and any special precautions or instructions

Question 4

Progress notes

Answer 4

• improvement of pt care
• should contain pt ID, date, and therapist signature
• should be written when pt’s condition changes during course of treatment
• specific frequency of notes is dictated by department policy

Question 5

Discharge summary

Answer 5

• usually conducted on last da of therapy

Question 6

10 tips for defensible documentation

Answer 6

1. Limit abbrevs
2. Date and sign all entries
3. Document legibly
4. Report progress towards goals regularly
5. Document at the time of the visit (POS)
6. Clearly identify note types (progress vs daily)
7. Include all related communications
8. Include missed or cancelled visits
9. Demonstrate skilled care and medical necessity
10. Demonstrate discharge planning though the episode of care