Evaluation and Documentation Flashcards
Client Documentation
Involves the written records that are kept regarding the actions taken for, with, and by the client.
Often become the official and legal record of client service, importance of thorough and accurate record keeping in therapeutic recreation services is a must.
“If it’s not in writing, it didn’t happen”
Types of documentation
Client management documentation and program management documentation.
Two functions are highly interrelated but serve different and distinct purposes.
Client management documentation
Includes all records that address individual client concerns.
Examples individual client assessment, individualized treatment or program plans, progress notes, discharge referral plan and summaries, and follow up or after care records.
Program management documentation
Includes all documentation that addresses groups of clients administrative, supervisory, or programmatic records. Examples include the therapeutic recreation program of operation, the comprehensive and specific program plans, and policy and procedure manuals.
Rationale for quality documentation
-assurance of quality services
-facilitation of communication among staff
-professional accountability and self-regulation
-compliance with administrative requirements
-provision of data for quality improvement and efficacy research
EHR
Electronic Health Record
Used to order prescriptions, track patients’ conditions, medications, allergies and test results.
Narrative Format Note
-Each professional group or source typically keeps separate from other professional groups or sources
-Often call source-oriented record keeping
-Relatively detailed account of activities that were performed for and by the client
-Client’s behaviors, interactions and other information relevant to the therapeutic recreation services are noted
There are few guidelines provided for the format of the narrative note
Staff member records events, activities, problems or issues in any logical order.
Problem Oriented Medical Record (POMR)
It focuses on the problems of the patient rather than the source of information.
Contains 5 components:
-database or initial assessment results that help determine the needs and plan of care
- client problem list related to diagnosis
-initial treatment plan including interventions and outcomes expected
-progress notes using SOAP, SOAPIE, SOAPIER formats
-discharge summary noting problems and resolutions (if achieved)
SOAP Note
Part of problem oriented medical record, it may be used for initial notes, progress notes, and discharge notes.
The following format it’s typically followed for each stated problem: subjective data, objective data, analysis, and plan.
S: subjective data, what client states about the problem, what client says he or she feels
O: objective data, what behaviors, science, or factual data the staff observes or measures
A: analysis, conclusion staff comes through, based on the interpretation of the subjective and objective data about the patient’s problem
P: plan, what the specialist plans to do about the problem now or in the future
Because SOAP fails to address interventions and evaluation aspects of care, SOAPIE and SOAPIER have been developed.
I: interventions, specific interventions implemented
E: evaluation, the patient’s response to interventions
R: revision, changes made from the original treatment plan.
Advantages of SOAP note
They have increased structure and organization, reflect the entire process of care, improve ability to track problems, complement more traditional care plans, foster communication among team members, and promote continuity of care.
Focus Charting
A method for organizing information in the narrative portion of the client’s record to include data action and response for each identified concern.
The narrative portion of focus charting progress note typically, although not always, includes 3 categories: data, action, response.
Additionally, the note ends with the plan section, describing the next progression of intervention.
DARP Note
D: Data: subjective and or objective information supporting the stated focus or describing observations at the time of significant events.
A: action: description of the actions taken by the therapist in the form of interventions or programs.
R: response: a description of the client’s response to the interventions, activities, or situation.
Client outcomes are included in this section, it can include a statement that treatment plan goals have been attained.
P: plan: next intervention to be implemented
Charting by Exception (CBE)
The purpose of CBE is to make trends in patients more obvious, by reducing the amount of time spent in documentation, and making current information about the patient status readily available.
Only findings that are significant, abnormal, or that deviate from professional standards or protocols are recorded, thus reducing repetitive charting.
Contains several components:
o Flow sheets
o Documentation referencing standards
o Protocols and incidental orders
o A database
o Diagnosis-based care plan
o SOAP (IER) progress notes
Treatment Plan Components
-Demographic background and history
-Referrals to and from therapeutic recreation services
-Assessment results/client problem areas
or deficits
-Client goals and objectives
-Action plan for client involvement
-Frequency and duration of participation
-Facilitation styles and approaches
-Staff and client responsibilities
-Reevaluation schedule
-Signature and date
Content of Progress Note
General behavior patterns, the circumstances surrounding attendance and participation, physical cues (i.e. hygiene and grooming, posture movement), environmental cues (i.e. social patterns, setting, surrounding objects).
Discharge and Referral Summaries
Major client problems or goals
Services received by the client
Client’s responses to functional intervention
Leisure education, and recreation participation services
Remaining problems or concerns
Plan for post discharge leisure involvement
