Evaluation and Documentation Flashcards
Documenting Assessment results
-summarize client’s strengths, weaknesses, the process used to collect assessment information, and treatment goals and interventions
-Each problem and strength should be written in objective measurable terminology
-narrative=written in paragraph form
-Problem-oriented medical records=lists
-source oriented records=TR section of chart
-problem-oriented=assessment or data base section of the chart
Progress notes
-CTRS must provide periodic updates on client’s progress toward meeting their goals
-frequency of updates is determined by agency guidelines, accreditation standards, and regulatory agencies
Modification of Plan
-clients needs and behaviors will change during treatment, so new goals, objectives, or supporting interventions may need to be adjusted on plan
Discharge/Transition plan
-should start the day the client arrives
-usually occurs when goals are achieved
-client should be involved in this in order for discharge to be successful
-Need to be included:
1. Major goals or problems
2. services received by client
3. client’s response to the intervention or services
4. received condition of patient when discharged
5. Specific referrals/information or instructions given to the client, family/caretakers, agency
6. Materials provided
7. Equipment recommendations
8. Specific recommendations for continued progress
Record-keeping systems
- Narrative charting:
-frequently used in community settings
-info must be about progress towards goals, but no uniform format - Problem-oriented medical records (POMR):
-way to organize a chart
-5 parts=initial assessment results, client problem list, initial treatment plan, progress reports using SOAP (SOAPIE or SOAPIER), and discharge summary - Charting by Exception (CBE):
-used in clearly detailed clinical pathway agencies or long-term care facilities
-only chart when there is a variance or exception from the typical course of recovery
SOAP, SOAPIE, and SOAPIER
-primarily used in hospital settings
-Subjective=direct quote from client
-Objective=data gather by observation of actions or behaviors
-Analysis=interpretation the CTRS makes from the S and O
-Plan=plan recommended based on previous info
-Intervention=specific intervention used
-Evaluation=how client responded to intervention
-Revision=changes made in original treatment plan
Electronic Health Record (EHR)
-patient’s computerized health record
-allows team to have easy access to a patient’s record and to easily enter assessment data and progress notes digitally
International Classification of Diseases 10th edition (ICD-10)
-used to classify disease and is written as a code
-code is given to each disease/disability/disorder
-used to compile health statistics and compare reports of disease occurrences between countries
-CTRS will not be coding but should understand the various codes
International Classification of Functioning, Disability, and Health (ICF)
-focuses on person’s health and functioning rather than disease like ICD-10
-provides codes that health professional score on a Likert scale to reflect a client’s level of impairment with:
1. body structure and function (mod impairment of frontal lobe, severe difficulty with short-term memory)
2. level of difficulty that a client has with a specific life activity (mild difficulty carrying out a daily routine)
3. barriers and facilitators that affect impairment and difficulty (attitude of family is a moderate facilitator, financial assets are a severe barrier)
Charting guidelines
-write legibly
-always use black pen
-don’t tamper or change records
-if error, draw a single line through it and then date and initial it
-do not vent anger or frustration with the family or patient in the chart
-document services provided and document if services are refused
-document any incidents
-sign and date every entry
If it is not documented…
…then it didn’t happen!
Roles of treatment team members
-most CTRS will co-treat with other professionals on the treatment team
-PT: help injured or ill people improve movement and manage pain; part of preventive care and treatment
-OT: help people, such as those with disabilities, live independently; help people meet goals needed for daily living and working
-CTRS may be brought in as a “consult”
-CTRS receives a referral from doctor or treatment team
Program evaluation
used to determine program effectiveness and to improve services
What should be evaluated
(things most important to department, agency, third-party payers, and received of services)
1. quality of services delivered
2. effectiveness of those programs
3. outcomes of those programs
How evaluation conducted?
- Differentiate between formative (ongoing and occurs while program is in progress where staff can make changes) and summative (end of program to compare programs or provide information for next session of programming) evaluation
- Use evaluation plan with specific data-collection instruments (questionnaires, observation, record documentation)
- CTRS must establish an administrative schedule for evaluation and determine collection for the TR program
