Lecture 11 - Documentation Flashcards
T or F: too much time is dedicated to documentation
FALSE, too little time
Purpose of documentation (6)
Pt. notes are considered legal documents
Method of communication btw therapists
Medicare/insurance reimbursement
Decisions to discharge (hospital)
Structure clinical decision making
Can be used for research
T or F: documentation is often used to determine how much should be billed for a visit
TRUE
Examples of uses of documentation by others
Make decisions about reimbursement
Decide discharge and future placement
Is used as a quality assurance tool
Is used as data for research on outcomes
4 things about legal aspects
- Handwritten entries should be legible and written in INK (black or blue)
- All notes must be dated when written, no backdating
- All notes must be signed, followed by the writer’s professional abbreviation
- Use a single line through an error, and write initials near the crossed-out word. Include date and time of correction
4 basic types of medical record documentation:
- The initial evaluation
- Daily or per session notes (on going)
- Re-examination or progress notes
- Discharge summary
Completed at visit, care given
To document impairments and functional limitations
Identify “diagnosis”, cause of functional limitations
Set goals and timeline (anticipated)
Specify a plan of care
Initial evaluation
Required for every visit encounter
States what the AT and patient have done, and why
Reports changes in patient/client status
Ongoing (daily) session
Update of patient/client status
Restate the goals
State what was done and why (therapist and patient)
Provides effectiveness of intervention in achieving the goals
When indicated, revision of goals
States how much longer intervention is anticipated
Provides justification for continued services
Progress note
Identifies criteria (met) or reason for discharge
Provides effectiveness and intervention summary on initial problem (meeting expected goals)
Outlines relevant recommendations for future
Discharge
Types of format for documentation
- Narrative
- Problem-oriented medical record
- SOAP
- FOR (functional outcome report)
Narrative format
Simple
Telling a story
Therapist derived outline
Specific info left to discretion of author
Cons of narrative format
Prone to omissions
High variability
Difficult to read/follow
POMR format
- Numbered list of patients problems
- When entering documentation, each professional refers to the number of the problem
- Produce a note using SOAP format
SOAP format
Subjective, Objective, Assessment, Plan
- Popular, now not linked to POMR
- Widespread acceptance
- Familiarity with the format
Subjective information (what you hear)
a. Patient’s description of his complaints, loss of
function, pain and date of onset.
b. Relevant data obtained from interview, including
patient’s self reported level of function
c. Patient’s home or work environment
d. Past medical history
Objective information (what you observe and do-measure)
a. Portions of patient’s chart (might include a
summary of recent surgery, and referral, laboratory
reports or x-rays)
b. Results of your examination
Assessment (what you think)
- Professional evaluation of overall impairments
based on integration of the subjective and objective
findings. - Identify and interpret problems, relate to overall
function. - Patient’s specific response to intervention
Plan (what you will do)
- What treatment is planned - continue or change
treatment. - Progression of the plan (short and long term goals).
- Education planned for patient/family.
- Frequency/duration of treatment.
- Follow-up; consultation with or referral to other
professionals
Pros of SOAP format
- Emphasizes clear, complete, and well-organized reporting of findings
- Natural progression from data collection to assessment to plan
Cons of SOAP format
- Associated with an overly brief and concise style
- Extensive use of abbreviations and acronyms
- Often difficult for nonprofessionals to interpret
FOR format
- increased emphasis on functional outcomes
- economics of health care
- document the ability to perform meaningful functional activities
- establishes the therapy rationale by linking impairments to the disability
Documentation takes many forms: (7 examples)
Written reports
Standardized forms
Charts and graphs
Drawings
Photographs
Videotapes, audiotapes
Physical specimens
Audience of documentation
Only other AT/PTs
Dr.s
Parents
Insurance
3 goal types
Disability goals
Functional goals
Impairment goals
Disability goals
Express the expected outcomes in terms of the specific roles that the patient wishes to be able to participate
Functional goals
Express the expected outcomes in terms of the skills needed to participate in necessary or desired roles
Impairment goals
Express the expected outcomes in terms of the specific impairments that contribute to the functional limitations
Essential components of a well-written functional goal
Actor
Behaviour
Condition
Degree
Expected time
Practice abbreviations at slides in ppt
53-54
See slide 51 for 10 common charting mistakes
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