Medical Documentation and Filing (E2) Lec 6 - PDF

ESSENTIALS OF DOCUMENTATION DR. AMANY HAMED ABOZAYED LECTURE 6  ▪ What Constitutes "Documentation"? ▪ Types of Notes ▪ Purposes of Note Writing Objectives ▪ Documentation Formats ▪ Forms of Documentation...

ESSENTIALS OF DOCUMENTATION DR. AMANY HAMED ABOZAYED LECTURE 6  ▪ What Constitutes "Documentation"? ▪ Types of Notes ▪ Purposes of Note Writing Objectives ▪ Documentation Formats ▪ Forms of Documentation ▪ Evidence-Based Practice: ▪ Abbreviations And Medical terminology: What constitutes "documentation"? ▪ Documentation is any form of written communication related to a patient encounter, such as an initial evaluation, progress note, flow sheet/checklist, reevaluation, or discharge summary. ▪ It encompasses the preparation and assembly of records to authenticate and communicate the care given by a health care provider and the reasons for giving that care. What constitutes "documentation"? ▪ Therapists should take pride in their professional writing; ▪ it is the window through which they are judged by other professionals.  In fact, it could be argued that documentation of services rendered is just as important as the actual rendering of the services.  Supervisors must recognize that good documentation takes time, and therapists must be provided with that time. What constitutes "documentation"? ❖ Despite its importance, documentation is often viewed negatively by therapists mostly due to :  First, and most obvious, too little time is dedicated to documentation in the clinic.  Second, therapists are given relatively little training in documentation. ❖ When proper guidelines and adequate training are provided, appropriate outcomes- based documentation does not have to be extremely labor- intensive. ❖ However, documentation is a skill that should be valued by therapists, educators, and supervisors, similar to any other physical therapy skill. Types of notes ❖ Four basic types of medical record documentation exist: 1. The initial evaluation 2. Treatment notes 3. Reexamination or progress notes, and 4. The discharge summary. 1. Initial examination/evaluation (Written by Physical Therapist): ❖Includes the following components: 1. Health condition 2. Participation and social history 3. Activities 4. Systems review 5. Impairments 6. Assessment (including evaluation, diagnosis, and prognosis) 7. Goals 8. Plan of care 9. Reason for referral 2. Treatment notes: (Written by Physical Therapist or Physical Therapist Assistant) for each therapy session: ❖Includes the following components:  Identify specific interventions provided, including frequency, intensity, and duration as appropriate.  Report changes in patient/client impairment, activity, and participation as they relate to the plan of care.  Response to interventions, including adverse reactions. 2. Treatment Notes:  Factors that modify frequency or intensity of intervention and progression goals, including adherence to patient-related instructions.  Communication / consultation with providers / patient/client / family / significant other.  Documentation to plan for ongoing provision of services for the next visit(s), which should include the interventions with objectives, progression parameters, and precautions, if indicated. 3. Progress Notes (Written By Physical Therapist): Includes the following components:  Provide an update of patient status over a number of visits or certain period.  Should include selected components of examination to update patient's impairment, activities, and/or participation status.  Provide an interpretation of findings and, when indicated, revision of goals.  When indicated, revision of plan of care, as directly correlated with goals as documented. 4. Discharge Summary (Written By Physical Therapist): Includes the following components:  Documents current physical/functional status.  Includes the degree to which goals were achieved and reasons for any goals not being achieved or partially achieved.  Provides a discharge/discontinuation plan related to the patient's continuing care. Purposes of Note Writing: PT documentation serves many purposes. These include : 1. Communication with other professionals: Ensures coordination and continuity of patient care. Organizes the planning of treatment strategies. 2. Clinical decision making: Documents patient's problems so that an appropriate plan of care can be established Purposes of Note Writing: 3. Creation of a legal record of PT management of a patient. Specifies that patient has been seen and that intervention has occurred. Serves as a business record. Is often used to determine how much should be billed for a visit. Purposes of Note Writing: Examples of Uses by Others: ▪ Make decisions about payment for services. ▪ Decide discharge and future placement. ▪ Used as a quality assurance tool. ▪ Used as data for research on outcomes. Documentation Formats: ▪ Many possible formats can be used for writing notes. ▪ Sometimes a facility or institution mandates a particular format. ▪ More often, use of a particular format is not officially required but is instead established by tradition and the desire for consistency. ▪ A particular format does not guarantee well-written documentation; it just makes the process easier. ▪ The principles of well-written documentation can be applied in any format. Documentation Formats: 1) Narrative Format 2) SOAP Format 3) Functional Outcome Report Format Documentation Formats: 1) Narrative Format  The simplest form of documentation  In this format, therapists can, and should, develop their own outline of information to cover.  These outlines can be more or less detailed.  The specific information listed in each heading is left to the writer's discretion, although some facilities provide guidelines for what should be covered under each heading. Documentation Formats: 1) Narrative Format  Because of the unstructured nature of narrative formats, the writer is prone to omissions, and there can be a high degree of variability (both within and among different writers).  If information is not included it is assumed it was not tested, whereas the writer may have inadvertently omitted the testing information.  Therapists must take particular care to be comprehensive in their documentation to minimize inconsistencies and maximize accuracy. Documentation Formats: 2) SOAP Format:  The SOAP note is a highly structured documentation format.  In this type of medical record, each patient chart is headed by a numbered list of patients problems (usually developed by the primary physician).  When entering documentation, each professional would refer to the number of the problem he or she was writing about. Documentation Formats: The SOAP format requires the practitioner to enter information in the order of the acronym's initials: Subjective / Objective / Assessment / Plan Documentation Formats: Documentation Formats: Documentation Formats: Advantages of SOAP Format:  It is widespread and is now widely used by different professionals, with much acceptance and the resulting familiarity  It emphasizes clear, complete, and well-organized reporting of findings with a natural progression from data collection to assessment to plan.  brief and concise style, including extensive use of abbreviations and acronyms, a style that is often difficult for nonprofessionals to interpret. Documentation Formats: Advantages of SOAP Format:  The SOAP format encourages a sequential rather than integrative approach to clinical decision making by promoting a tendency to simply collect all possible data before assessing it.  Thus, while the SOAP note does not provide the ideal format for an initial evaluation, it can be adapted to reflect functional outcomes and thus provides a useful framework for documenting treatment notes and progress notes. Documentation Formats: 3) Functional Outcome Report Format:  The FOR format is a relatively new documentation format.  It was developed due to increased emphasis on functional outcomes.  The FOR format focuses on documenting the ability to perform meaningful functional activities rather than isolated musculoskeletal, neuromuscular, cardiopulmonary, or integumentary impairments.  When the format is implemented properly, FOR documentation establishes the rationale for therapy by indicating the links between such impairments and the participation restrictions they cause in patient. Documentation Formats: 3) Functional Outcome Report Format:  FOR documentation also emphasizes readability by health care personnel not familiar with PT jargon (at the expense of increased time to write the documentation).  More important, it promotes a style of clinical decision making (PT diagnosis) that begins with the functional problems and assesses the specific impairments that cause the activity limitations or participation restrictions. Documentation Formats: 3) Functional Outcome Report Format:  FOR documentation also emphasizes readability by health care personnel not familiar with PT jargon (at the expense of increased time to write the documentation).  More important, it promotes a style of clinical decision making (PT diagnosis) that begins with the functional problems and assesses the specific impairments that cause the activity limitations or participation restrictions. Forms of Documentation ▪ Documentation takes many forms, including 1. Written reports, 2. standardized assessments, 3. graphs and tables, and 4. photographs and drawings. Forms of Documentation 1. Written reports: Most commonly, PTs use a written report to document their findings from an evaluation or convey what has occurred in a patient visit. The format of this report can take many forms; the two most common are a narrative format and a SOAP format. In this text, we use a narrative format for documenting an initial evaluation. For progress notes and for treatment notes, we recommend using a SOAP format. Forms of Documentation 2. Standardized assessments:  The use of standardized assessment tools is an integral part of PT documentation.  Standardized outcome measures are measures that have been determined to be reliable and ideally validated in specific patient populations.  Although outcome measures are most commonly used in PT research, their use in everyday documentation is essential. Forms of Documentation 2. standardized assessments:  Standardized measures are very useful to be able to quantify improvements in patient performance and demonstrate the value of therapy services.  Hundreds of outcome measures are available to therapists measuring at all levels of disablement.  When choosing a standardized test, therapists must consider the purpose and design of the tool before using it for evaluative purposes. 2. standardized assessments: ❖ The most common types of standardized measures:  Descriptive: a descriptive assessment provides information that describes the person's current functional status, problems, needs, and/or circumstances.  Discriminative: a measure that has been developed distinguish between individuals or groups on an underlying dimension (test score) when no external criterion or gold standard is available for validating these measures.  Predictive: predicts the ability or state of a person or a specific outcome in the future.  Evaluative: used to detect change over time; undertaken to monitor a client's progress during rehabilitation and used to determine the effectiveness of the intervention. 2. standardized assessments: ❖ The therapist must have knowledge of the reliability and validity of an evaluation tool and understand the purpose for which the tool was designed to use it properly. ❖ In addition, therapists must consider the sensitivity of a measure: Was it designed to adequately capture changes in a patient’s status that may occur as a result of intervention? 3. Graphs and Tables: Graphs can be used as a form of documentation to provide a visualization 3. Graphs and Tables: Tables are another format of documentation that can be used in the initial evaluation, both to document multiple findings of a similar impairment or functional skill and in progress reports to demonstrate changes over multiple sessions. 3. Graphs and Tables: 4. Photographs and Drawings: ❖ Some aspects of patient care are difficult to describe narratively but may be best explained visually. ❖ Photographs (obtained with the patient's written consent), can be used very effectively for documenting impairments such as posture or wound size or for documenting functional abilities. 4. Photographs and Drawings: Evidence-Based Practice: American Physical Therapy Association supports and promotes the development and utilization of evidence-based practice that includes the integration of best available research, clinical expertise, and patient/client values and circumstances related to patient/client management, practice management, and health policy decision making. It is therefore critical that evidence-based practice be fully integrated into clinical documentation. This is most important in documentation of the initial evaluation and plan of care as well as during documentation of treatment notes, when specific intervention strategies are reported. Abbreviations And Medical terminology: ❖ The first question that must be addressed regarding use of abbreviations is who will be the reader of this note? If the answer is another physical therapist or physical therapist assistant (and no other person), therapists can freely use abbreviations and appropriate PT terminology. ❖ However, if only a slight possibility exists that the note might be read by another professional (e.g., physician or nurse) or by a nonprofessional (e.g., administrative staff, claims auditor, member of a jury), uncommon abbreviations and jargon almost certainly will impede understanding. Abbreviations And Medical terminology: Furthermore, if the writer is in doubt about the use of an abbreviation, it is best to spell out the word. The time saved writing an abbreviation may not be worth it if it cannot be interpreted by anyone else. Clearly, common medical abbreviations can be useful time-saving devices. Abbreviations And Medical terminology:  Hospitals and health care facilities often develop their own list of abbreviations that are considered acceptable in that institution.  PTs and PTAs should follow guidelines set by individual institutions when considering the appropriateness of specific abbreviations. Abbreviations And Medical terminology: Certain types of documentation are intended for the primary readership of the patient. For example, a home exercise program should be written in lay terminology, avoiding abbreviations and medical jargon. Similarly, any documentation that is sent, and particularly to patients or their families, should make more limited use of abbreviations. If uncommon medical terminology is used, it should be defined in layperson's terms. Another example is note writing in pediatric practice, in which developmental evaluations are read primarily by parents, educators, service providers, and coordinators. Professional notes should not be written in purely lay terminology, but they can be written in such a way as to be readable by those outside the profession. Abbreviations And Medical terminology: The overuse of abbreviations and jargon is a symptom of a more serious problem: the use of a private language in which much of the rationale for treatment is left implicit. If it is assumed that the reader of a note is among the cognoscenti, in which he or she must be able to understand the abbreviations and strange terms, then why bother explaining what was done and why? Too often it seems as if such a philosophy guides the writing of notes. The critical elements of the clinical reasoning process cannot be omitted with the assumption that the reader will fill in the blanks. The therapist has a professional responsibility to explain what has been done & what will be done, and why, in clear, unambiguous terms that will be understandable to all those authorized to read a therapist's notes. Abbreviations And Medical terminology: Omit Unnecessary and Irrelevant Facts: The best way to write clear, concise notes quickly is to avoid unnecessary and irrelevant facts and conclusions. Merely because the therapist has observed something does not make it appropriate to include in the note. The note should include only those observations and interpretations that are essential for documenting the patient's current medical condition. Omitting nonessential items makes the note more readable and more efficient to write. Therapists should generally avoid, or be very careful, when including the following information in a medical note:  Detailed social history  Detailed living situation  Family history  Detailed history of other medical conditions that have been resolved and do not affect the current condition Therapists should use their knowledge of individual diseases to help guide what is considered pertinent for a medical note. In general, documentation should be kept focused to the information that directly affects that patient’s current health condition. THANK YOU