Therapist Field Documentation Essentials

Field Documentation

• Field documentation is crucial in various professional settings, particularly for therapists.
• It's vital for valid informed consent and reducing litigation risks.
• Documentation is a significant aspect of any professional life.

Purpose of Documentation

• Primary purpose: To record the care given and supporting evidence, protecting both the therapist and patient in case of questions arising about the care received.
• Medical records are legal documents subject to subpoenas in medical-legal investigations.
• Documentation supports actions, statements, and observations during emergencies.

Purpose of Documentation (Continued)

• Communicating treatment information to other healthcare professionals.
• Serving as a personal reference for tracking progress, regressions, and previous findings.

Critical Perspective of Documentation

• Documentation is critical from ethical, legal, and professional perspectives.

Why SOAP Format?

• SOAP is a standardized medical format, considered a legal document.
• Modifications are not permitted—no erasing is allowed; adding is permissible.
• The format ensures consistency and understanding among medical professionals.
• It's written in pen and signed at the end of each entry.

SOAP Format

• SOAP stands for Subjective, Objective, Analysis, and Plan.
• These are four crucial elements of medical documentation.

Examples of Subjective Findings

• Chief complaint
• Mechanism of Injury (MOI)
• Events leading up to injury
• Pain experience
• Previous injury information
• Athlete's statements

Examples of Objective Findings

• Swelling
• Heat
• Redness
• Range of motion
• Strength
• Palpations
• Observable/measurable data

Important Considerations

• Liability is more related to omissions rather than inclusion within the record.
• Inadequate documentation can be misinterpreted as lack of performed test or measurement.

Analysis Section

• Analysis reflects your index of suspicion or your diagnosis of the condition.
• It should accurately reflect your assessment findings.
• Your analysis guides your actions.

Plan Section

• The Plan section outlines immediate and future actions.
• It should include referrals, follow-up recommendations and other necessary instructions.

Example of Plan

• Applying appropriate principles (pier principles, parameters)
• Educating the patient about these principles
• Requesting physician follow-ups
• Communicating with the athlete and parents about injuries.

Sample Scenarios

• The scenarios present situations requiring immediate field interventions and documentation.
• Thorough assessments and clear reasoning determine the athlete's best course of treatment and follow up.

Concussion/C-spine Cases

• Specific actions, details, and observations for handling concussion cases are essential.

When to Document

• Any time medical care or medical advice is given.
• The documentation must clearly establish the reasoning behind the decisions made, usually presented in SOAP format.

Additional Documentation Scenarios

• Documentation is also mandatory if the patient refuses care or if there are disagreements about care or medical advice.
• Comprehensive documentation is needed in confrontational situations.
• Brief narrative paragraphs within the main documentation are used when significant events occur that do not necessarily fit into the SOAP format (i.e., refusal of care, disagreements about care, or other significant non-assessment-related situations).

Record Confidentiality

• Maintain confidentiality through appropriate coding methods.
• Store private information in secure locations.
• Do not leave logbooks in open or accessible areas.

Retaining Documents

• All medical documents are securely and safely maintained.
• Documents are retained for 10 years after the last entry.
• For minors, documents are retained until the athlete turns 18.

Explore the essential aspects of field documentation for therapists, including its importance for informed consent and legal protection. Understand the roles of documentation in care recording and communication among healthcare professionals. Learn about the SOAP format for effective documentation.