INTRODUCTION TO DOCUMENTATION

PREPARED BY: FLORIZA P. DE LEON, PTRP

PURPOSES OF DOCUMENTATION
Patient care notes record what the therapist does to manage the individual patient’s case. Ensure that the rights of the therapist and the patient are protected

Considered as legal documents
Good documentation is a method of communicating with all other health care professionals The goal of such communication is to provide consistency among the services provided by various health care professionals For third party payers. Important in making decisions about reimbursements Decisions can be greatly influenced by the quality and completeness of the note Charts are reviewed for decision making regarding next procedures for the px Documentation helps the therapist to organize the thought processes involved in px care. Excellent method of structuring thinking for clinical decision making Documentation of px care can be used for quality assurance and improvement purposes Patient care notes can be used in outcome research.

SOAP
S – subjective O – objective A – assessment P – plan

COMPONENTS OF THE PATIENT/CLIENT MANAGEMENT NOTE
 History  Systems review  Test and measures  Diagnosis

 Prognosis
 Plan of care

TYPES OF NOTES
Initial Note/Initial Evaluation – written after the first examination and evaluation and documents the examination, evaluation, diagnosis, prognosis, and plan of care Progress/Interim Notes – written periodically, reporting the results of re-examination and re-evaluation and changes in the prognosis and plan of care, as needed Discharge notes/summary – written at the time that therapy is discontinued, after a final examination and evaluation are performed; addresses the results of the final examination and evaluation, the outcomes and goals achieved, a summary of the interventions received, and the final disposition of the patient

GUIDELINES IN CHARTING
Accuracy Brevity Clarity

Example Brief Pt. amb 10 ft in // bars indep. But required min assist of 1 to turn around in // bars. Sit ↔stand from w/c indep. Using // bars for support. Long and windy Once the patient wheeled to the // bars and positioned himself in front of the // bars, he locked his w/c, raised the foot plates, and scooted forward from the seat of the chair. He then gripped the // bars with his hands and on the count of 3 was able to pull himself up to a standing position without any assist, from the therapist. Once standing, he was able to ambulate by positioning his arms forward and then taking steps. He could lead with either right or left foot. Upon turning in the // bars, he was unable to let go with one arm to pivot his body around. Therapist had to give some support until the patient was turned around and both arms were back on the // bars.

Example Incorrect Pt. stated she lived alone. Describes 5 steps s hand railing of her 1story house. Denied previous use of assist. Device Correct States lives alone. Describes 5 steps s hand railing at entry of her 1-story house. Denies previous use of assist. device.

Example

Vague “ROM is ↑” “feeling better” amb c some assist”
Clear “(R) shoulder flexion AROM is ↑ to 0-70” “pt. states she knows she is feeling better, indicated by her ability to perform light housekeeping tasks for = 2 hrs a tiring.” “pt. amb c walker NWB (L) LE for = 20 ft x 2 c min +1 assist

EXAMPLES OF ERRORS IN ACCURACY, BREVITY, AND CLARITY
INCORRECT: Pt. was unable to perform activity due to muscle absence. (inaccurate and unclear) CORRECT: …due to muscle paralysis INCORRECT: Watch for return of absent muscles (unclear and inaccurate) CORRECT: Re-examine prn for motor return INCORRECT: Pt. is sore (too brief; unclear) CORRECT: Pt. is hypersensitive to touch INCORRECT: Pt. didn’t have any tightness. (wordy; unclear) CORRECT: no ROM limitations noted. INCORRECT: Had his (R) leg cut off because of circulation problems (wordy) CORRECT: (R) transtibial amputation 20 to PVD INCORRECT: Pt. was unable to wiggle toes when asked to. (wordy) CORRECT: Pt. was unable to wiggle toes upon request. INCORRECT: Examination was incomplete because of pt. confusion. (wordy and unclear) CORRECT: Examination incomplete 20 to pt’s inability to follow commands.

PUNCTUATION
•Hyphen (-) •Should be avoided in notes because they can be confused with the minus signs used in mm grades or negatives (as in SLR – on (R)) •Exception is in ROM •Semicolon (;) •Instead of overusing “states” in the subjective part of the note, a semicolon can be used to connect two related statements. •Colon (:) •Can be used instead of is Ex: Instead of “AROM (R) shoulder flexion is 0-90,” you could say “AROM (R) shoulder flexion: 0-90” Example Wordy “states position of comfort for sleep is on (R) side. States pain does not awaken pt. at night.” Brief “states position of comfort for sleep is on (R) side; pain does not awaken pt. at night.”

Correcting errors Makes it look as if the health professional is trying to “cover up” malpractice

Put a line through the error, write the date and initial it above the error
Signing Your Notes Should sign every entry that you make into the medical record. All notes should be signed with your legal signature (your last name and legal first name or initials.) No nickname should be used. Initials should follow your name indicating your status as a therapist or therapist assistant

Referring to yourself
Notes discuss the patient and not the therapist Ex: INCORRECT: I helped this patient transfer c min. assist. from his w.c to the plinth CORRECT: Pt. transferred c min assist, w/c↔plinth Blank or Empty Lines Empty lines should not be left between one entry and another, nor should empty lines be left within a single entry Empty lines are areas in which another person could falsify I nformation already charted. Writing orders in a Chart FORMAT: date/time/order v.o. physician’s name/therapist’s signature, PT

-

EXAMPLE: 12-24-2001/10:50/Pt. may be FWB in PT
v.o. Dr. Ache/ Sue Brown, PT

Sign up to vote on this title
UsefulNot useful