ppcm 1: documentation & the patient record

documentation purposes

Legal document

Communication

Advocacy

Discharge plans/additional care

Quality assurance

how does documentation provide quality assurance?

Record of therapist's clinical decision making

Improving standards of care/ compliance with accrediting boards

Outcomes research/Sources of therapist reflection

Education of new staff

how does documentation provide communication?

helps other HCP, details POC, goals, provides consistency in times of absence

how does documentation advocate?

assisting patients in obtaining insurance coverage

Reimbursement justification

keeping records secure paper documentation secure

Limit access to file room

Keep under lock and key

Do not leave records out

Develop Policy & Procedures pertaining to fire, water, threats

keeping records electronic medical record system EMR

Many different EMR companies (site specific)

Password protected for EMR Never share password Change password often

Restrictions on print function

Using "time-out" monitor settings

Recovery/backup plan

HIPPA compliance

Private health information, protecting patient specific information from disclosure

Shall not release info without obtaining prior consent unless to referring physician

Need specific authorization from patient or court order, can disclose if it will protect welfare of patient or community

General Rules; Documenting in the patient record

Use black ink when using paper notes

Abbreviations: Ensure correctness & facility-specific approval

Authentication / Signature: Every entry must be signed, dated, and time-stamped with therapist's license # included

Error management: Single line through error, therapist's initial and date above error

Blank or empty lines should be avoided or with a single line through

When documenting, refer to yourself in 3rd person, "the therapist."

Consider the ABCs of Documentation (Accuracy, Brevity, Clarity)

ABCs (and D) of Documentation

Accuracy: factual, non exaggerated, not made up

Brevity: concise and succinct, abbreviations used correctly

Clarity: Clear documentation

Defensible : Must justify services and protect therapist

What to Maintain in the PT/Client Record

Signed consent for treatment

Examinations/Re-exams

Discharge summary

HEP's

Referral/prescription, if indicated

Including special reports or results of objective tests or measures

Daily visit/encounter notes and summary of progress

Letters/communications

Privacy notice receipt acknowledgement

Plan of care if not contained in the evaluation/reevaluation

Including missed sessions and "no shows"

Flow sheets/exercise forms

Insurance verification (if applicable)

Equipment information

Progress Notes

Service / Billing / Activity logs

The Patient/Client Management Note

Described in the Guide to Physical Therapy Practice

Document organized in the following format:

History

Systems Review

Tests and Measures

Evaluation

Diagnosis

Prognosis

Plan of Care

SOAP Note

Developed in the early 1970's

S : subjective

O: objective

A: assessment

P: plan

SOAP: Subjective

Information received by patient or significant other

Try for verbatim

HPI

C/C

PLOF

Pt's goals

Pt relays information about medical &social hx, employment, living environment, health habits, family hx, activity level, medications, response to interventions, anything patient reports that is relevant

Review of systems (per the patient)

SOAP: Objective

Tests and measures

Specific objective findings

SOAP: Assessment

Evaluation: Links clinical presentation with clinical and functional impairments and activity limitations/participations restrictions

Justification for recommendations

Inconsistencies, further testing

Possible Referral to other practitioners

Diagnosis - PT diagnosis

Prognosis Prediction of improvement and outcome, factors influencing, justification for decision

SOAP: Plan

Plan Proposed interventions including frequency, duration, length of episode of care Goals

SOAP note: Assessment aimed to...

Why does the patient present the way they do?

Why/how are the patient's clinical impairments impacting activity and participation?

What/Why did the patient struggle or succeed during the session?

What do we as the PT think the patient still needs to work on?

SOAP note assessment includes:

Tolerance to/response to interventions

Avoid only stating that the patient "tolerated Rx well"

Need to have a rationale for this statement

Any changes in presentation or clinical impression or plan of care

Overall impression or progress, regression, or unchanged status.

initial exam vs. daily encounter notes?

daily note: Concise and thorough snapshot of 1 treatment session. DO not detail ALL tests and measures/ impairments but log the activities completed and patient performance during the session

IE:

more exhaustive and lengthy

more tests and measures

capture the entire intended POC and projected outcomes during the session

IE notes must include

Thorough Patient Interview and history Social history Patient goals

Objective: Full Systems Review, tests and measures, standardized assessments performed

Physical Therapy evaluation: (the assessment) A synthesis of the tests and measures and how they relate to the patient’s clinical presentation, components of the ICF, and overall therapy needs.

Physical Therapy Diagnosis, Prognosis, and full POC (frequency, duration, intended length of episode of care, measurable goals)

Re-examination/Re-evaluation or Progress Notes

A modification or redirection of the plan

Update of status

Interpretation of the data

Revision of goals / outcomes

Should be completed with any significant changes in status, hospitalization, or new surgery/procedure that directly impacts patient presentation

Discharge Note

Details the conclusion of the patient's episode of care

-Outcomes status (Achieved or not possible reasons)

-Current status

-Discharge Plan

Incident Report

A detailed record of the exact event leading up to and including the fall/ injury/near miss /event

Must be filled out immediately after the event occurs after the patient is stable /has received medical care as needed

Most incidents are written in response to patient falls, however, incident reports can /should be written for any employee or visitor injury/event

Patient complaints

Student injury or events: Typically, not written in the patient's chart but rather are filed in a different area•

Incident reports can be subpoenaed in legal proceedings

Incident Report includes

Exact time/date and contributing factors

People involved /witnesses to the event