Documenting Goals Flashcards
Why do we document?
- communication
- legal record
- discharge planning
Why is documentation important?
- demonstrates compliance
- demonstrates skilled services
What are the types of notes?
- Initial note/eval
- Daily note
- Progress note/re-eval
- Discharge note
Characteristics of an initial note/eval
- 1st visit only
- includes the initial evaluation and plan of care
Characteristics of daily note
recorded at each visit
Characteristics of progress note/re-eval
- every 10 visits or every 30 or 60 days
- written when patient’s condition changes unexpectedly or does not progress as expected
Characteristics of a discharge note
written after the final visit
What is included in the chart?
- History
- Systems review
- Tests & Measures & Outcome Measures
- Evaluation (diagnosis, clinical impression)
- Prognosis
- Anticipated Goals & Expected Outcomes
- Frequency & Duration of the Episode of Care
- Intervention Plan
What should be considered when choosing tests and measures?
- they are highly dependent & variable on the patient population and diagnosis
- they will vary based on each patient and situation
What should be considered when recording tests and measures?
- they should be organized into categories to improve readability (types of tests/measures, areas of the body, functional skills)
- it should be full of brevity and clarity
What must be recorded when documenting goniometry?
- type of ROM assessed
- joint, which motion, measurement taken
- don’t use negative numbers
What are the categories of outcome measures?
- self-reported
- performance based
What is considered self-reported outcome measures?
- patient or client satisfaction
- pain
- QOL
- condition-specific
- patient-specific or client-specific
Who should goal writing be clear to?
- you
- your colleagues
- your patient or client
- your patient or client’s caregivers
- any user of your documentation
What should goal writing be used to determine?
- progress (allow for adjustments of your clinical impression)
- prognosis, duration, and frequency of the episode of care
- conclusion of care and intervention plan
