Computerized Documentation



Computerized Documentation


Janet Herbold



LEARNING OBJECTIVES


After reading this chapter and completing the exercises, the reader will be able to:


1. Identify and describe the benefits of an automated documentation system.


2. Discuss the various uses of patient data obtained from computerized documentation systems.


PTs, regardless of the setting in which they work, are always key members of the patient care team. Because the PT is a member of the patient-centered team, the success of the patient encounter often depends on the communication among other multidisciplinary members. Communication between practitioners in the health care environment has often been a challenge. Health care today faces constant pressure to decrease costs, reduce waste, and provide care in a safe environment using the best-known practices of medicine. A paper-based documentation environment includes inherent barriers to improving efficiency, safety, and quality. These limitations are some of the major reasons the goal of an electronic medical record, championed by the Bush administration with continued support by President Obama, is so important. Making patient information immediately accessible and easily transferable between patient-practitioner encounters is proposed as one of the most important advances of the twenty-first century.



Evidence for Electronic Medical Records


The literature provides some evidence of the success of electronic medical records but also illustrates some of the pitfalls. In a systematic review, Wu and Straus (2006) reported improved documentation in terms of patient encounter time, more use of standard variables, and improved diagnostic accuracy using a handheld electronic medical record (EMR) compared with a paper-based system in an orthopedic practice. Several nursing articles have discussed the benefits of the EMR for completeness of nursing documentation as perceived by the physician (Green & Thomas, 2008) and have reported a slight decrease in routine nursing documentation time (Hakes & Whittington, 2008), although the finding approached but did not reach significance. Clinician perception of a newly implemented EMR can play a role in its success or failure. El-Kareh et al. (2009) reported that although clinicians may perceive some initial problems with a new electronic health recording system, they are significantly more receptive to it within 1 year of its implementation.



Electronic Records in Physical Therapy Practice


A literature review in MEDLINE and CINAHL (1985-2009) yielded no results regarding the use of an EMR in physical therapy clinics or among these clinicians. Traditional physical therapy documentation has been done with pen and paper. Some clinics and institutions use only narrative notes, whereas others have migrated to preprinted forms. Preprinted forms are one way in which physical therapy documentation has become more standardized in the past few decades. But as more health care facilities adopt computer documentation systems, a gradual shift will be seen in computer use in physical therapy practices and departments. Many institutions have already made the transition to computerized documentation.


This chapter discusses some of the drawbacks to pen and paper documentation that would lead a clinic or practice to move toward computerized documentation. We further highlight the pros and cons of using computerized documentation in physical therapy practice and highlight some considerations for choosing a computer package that best meets the needs of an institution.



Drawbacks to Pen and Paper Documentation


Inherent drawbacks to the pen and paper method of documentation include the following:



• Legibility of the notes. Illegibly handwritten notes can lead to miscommunication, errors in practice, and denied payment.


• Redundancy of medical and demographic information. Therapists frequently copy information written by another health care professional into their own notes. Components such as the patient’s diagnosis, date of birth, past medical history, and medications are frequently manually rewritten into therapy documentation. In addition, as the completion of regulatory forms such as the Inpatient Rehabilitation Form–Patient Assessment Instrument (IRF-PAI), the Minimum Data Set-Resource Utilization Groups (MDS-RUGS), and the Outcome and Assessment Information Set (OASIS) become necessary for reimbursement and payment, therapists and nurses must document both in the medical record as well as on the reimbursement form (Figure 15-1). Both practices result in redundancy and duplication of information at a time when efficiency of clinical practice and staff productivity are being scrutinized.


• Difficulty with data retrieval for clinical research or outcomes analysis to promote evidence-based practice. It has become increasingly important to demonstrate treatment effectiveness through clinical research. With handwritten documentation it is very difficult and time consuming to manually review charts and analyze notes to determine the effectiveness of treatment techniques. In many cases, the variation in note-writing style and terminology makes it impossible to extract comparative data from handwritten notes from different clinicians even for the same type of patient condition.


• Use of abbreviations. Abbreviations have been used for many years as a shortcut during handwritten documentation. This practice, although frequently time saving, can lead to errors in legibility and a multitude of terms meaning the same thing, thus creating confusion among clinicians.


During an age of maximizing productivity, accessing clinical data to report outcomes and a shrinking length of stay in patient days, therapists look for creative ways to streamline documentation in a method that reduces redundancy and errors and facilitates data retrieval. As a result, some facilities have sought assistance from the world of automation and have purchased or developed computerized therapy records.



Benefits of Computerized Documentation


Some benefits of computerized documentation in physical therapy practice are listed in Box 16-1.



BOX 16-1   Benefits of Computerized Documentation





STANDARDIZATION OF DATA ELEMENTS AND CHARTING PRACTICES


A computerized system can create a standard data collection tool format for the initial evaluation, treatment notes, reevaluations, and discharge evaluations. Therapists can use a variety of devices to access and chart in the electronic medical record. Laptops and handheld devices allow clinicians to document their services during the patient evaluation and treatment encounter with the patient present. Therapists naturally become faster and more efficient note-writers through repetition and practice. In addition, training of new or rotating staff is made easier and more consistent throughout the organization. Computerized documentation allows for consistent collection of data elements within a patient type, in which the same information can be captured in the same order for all patients. This helps those reading the documentation as they become familiar with the format over time and allows them to locate pertinent information quickly and easily. Automation also can eliminate the use of abbreviations and reduce the need for interpretation when the written documentation is unclear and unknown.


Figure 16-1 illustrates these features in a software program (MediServe Information System, Chandler, Ariz.) with templates designed by a team of rehabilitation professionals (Burke Rehabilitation Hospital, White Plains, NY). In this example, the Impression/Assessment is coded to include key components, such as summarizing and drawing relationships between the patient’s impairments, activity limitations, and participation restrictions. All possible options for each of these components are listed as options in a pull-down menu (in this example, Life Role Participation). By using such a format, therapists are prompted to provide critical information so that it is always included in their documentation. Furthermore, the design of the template is structured so that the terminology is consistent with current practice and, importantly, the Guide to Physical Therapist Practice (American Physical Therapy Association, 2001).


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FIGURE 16-1 Computerized documentation template for the Assessment section of an initial evaluation. Selection lists are available at various points throughout the documentation. This figure illustrates the output of selection lists of impairments and functional (activity) limitations.
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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Computerized Documentation

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