Essentials of Documentation

Essentials of Documentation

• Documentation is any written communication about a patient encounter, including initial evaluations, progress notes, flow sheets, re-evaluations, and discharge summaries.
• Documentation authenticates and communicates the care provided and the reasons for it.
• Therapists should take pride in their writing as it is how they are judged by other professionals.
• Documentation is just as important as the treatment itself.
• Supervisors must recognize that good documentation takes time and therapists must be provided with the necessary time.
• Time constraints and lack of training are common reasons why documentation is viewed negatively.

Objectives

• Understanding what constitutes documentation
• Identifying types of notes
• Understanding the purposes of note writing
• Learning different documentation formats
• Learning forms of documentation
• Incorporating evidence-based practice
• Understanding abbreviations and medical terminology

What Constitutes "Documentation"?

• Documentation is any written communication related to a patient encounter.
• This includes initial evaluations, progress notes, flow sheets/checklists, re-evaluations, and discharge summaries.
• Records are prepared and assembled to authenticate and communicate the care given and the reasons for it.

What constitutes "documentation"? (Continued)

• Therapists are judged by other professionals based on their documentation.
• Proper documentation is as crucial as the actual treatment rendered.
• Good documentation takes time, supervisors must recognize this and provide therapists with the necessary time.

What constitutes "documentation"? (Continued)

• Despite its importance, therapists sometimes view documentation negatively due to limited time and training.
• Inadequate time and training result in clinicians not properly documenting their work.
• Well-structured guidelines and appropriate training improve documentation quality.

Types of Notes

• Four basic types of medical record documentation exist:
  • Initial evaluation
  • Treatment notes
  • Re-examination/progress notes
  • Discharge summary

1. Initial Examination/Evaluation

• Prepared by the physical therapist.
• Key components include:
  • Health condition
  • Participation and social history
  • Activities
  • Systems review
  • Impairments
  • Assessment (including evaluation, diagnosis, and prognosis)
  • Goals
  • Plan of care
  • Reason for referral

2. Treatment Notes

• Prepared by the physical therapist or physical therapist assistant for each therapy session.
• Key components include:
  • Identifying interventions (frequency, intensity, and duration)
  • Reporting changes in patient/client impairment, activity, and participation, relating to the plan of care.
  • Recording responses to interventions, including adverse reactions.
• Factors modifying intervention frequency or intensity include adherence to patient instructions, communication/consultation with providers, family, significant others
• Documentation should include the plan for ongoing services, with objectives, progression parameters, and precautions.

3. Progress Notes

• Prepared by the physical therapist.
• Components include:
  • Updating patient status over a period of visits or a specific period.
  • Including selected examination components to update the patient's impairment, activities, and participation.
  • Interpreting findings and revising goals as needed.
  • Revising the plan of care, correlated to goals.

4. Discharge Summary

• Prepared by the physical therapist.
• Components include:
  • Documenting current physical/functional status
  • Detailing the degree to which goals were achieved and reasons for any goals achieved or not completely achieved
  • Providing a discharge/discontinuation plan related to the patient's continuing care

Purposes of Note Writing

• Communication with other professionals
  • Ensuring coordination and continuity of patient care
  • Organizes planning for strategies
• Clinical decision making
  • Documents patient problems to establish an appropriate care plan
• Creating a legal record of patient management
  • Specifies that the patient was seen and intervention occurred.
  • Serves as a business record.
  • Is used to determine billing for the visit.
• Examples of use by others
  • Make decisions about payment for services
  • Decide discharge and future placement
  • Used as quality assurance tools
  • Used as data for research on outcomes

Documentation Formats

• Various formats exist for documentation, but no single format is universally required.
• Examples of formats:
  • Narrative
  • SOAP
  • Functional Outcome Report (FOR)

1. Narrative Format

• Simplest format
• Therapists create their own outline of information to cover
• Outlines can be detailed or less detailed
• Discretion in content for each heading (guidelines may be provided by facilities)
• Prone to omissions and variability, information missing may be assumed as not tested.
• Accurate and comprehensive documentation is crucial.

2. SOAP Format

• Highly structured format
• Patient charts are headed by a numbered list of patient problems often developed by the primary physician
• Professionals use the number of the patient problem when entering documentation
• Subjective, Objective, Assessment, Plan in the order of documenting

3. Functional Outcome Report (FOR) Format

• Relatively new documentation format
• Developed from emphasis on functional outcomes.
• Documents the ability to perform meaningful functional activities.
• This documentation format links functional impairments to participation restrictions.
• Readable by health care personnel not familiar with PT jargon.
• Promotes a style of clinical decision-making starting with functional problems and assessing impairments.

Forms of Documentation

• Written reports (often using narrative or SOAP format)
• Standardized assessments (evaluative measures, reliable and validated, needed in research and everyday documentation)
• Standardized measures are needed to quantify improvements, and demonstrate value of therapy
• Graphs and tables (used for visualization, for identifying a pattern of progress; for documenting multiple findings of similar impairments)
• Photographs and drawings (visual aids, obtained with the patients consent, for documenting things difficult to describe in words like posture or wound size)

Evidence-Based Practice

• American Physical Therapy Association emphasizes the use of evidence-based practice, including integration of research, clinical expertise, and patient/client values.
• Evidence-based practice is vital for initial evaluation and plan of care documentation but is critical for treatment notes when intervention strategies are documented

Abbreviations and Medical Terminology

• Consider who will be reading the notes when using abbreviations
• If another professional may be reading it, avoid uncommon abbreviations and use clear, understandable terms.
• Spell out the word if unsure about the abbreviation's use
• Common abbreviations can conserve time

Omit Unnecessary and Irrelevant Facts

• Write clear, concise notes.
• Only include essential observations and interpretations for the patient's current condition.
• Avoid irrelevant facts and conclusions merely because they are observed.

Information to Avoid in Medical Notes

• Detailed social history
• Detailed living situation
• Family history
• Detailed history of resolved medical conditions that don't affect the current condition.
• Focus documentation on information directly affecting the patient's current health condition

This quiz covers the fundamentals of medical documentation, including its importance in patient care and communication. You will learn about various types of documentation, formats, and the role of evidence-based practices in writing notes. Enhance your understanding and skills in effective documentation as a healthcare professional.