Documenting Reason for Referral: Participation and Social History,



Documenting Reason for Referral


Participation and Social History



LEARNING OBJECTIVES


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


1. Describe the components of documenting participation, social history, and general health status.


2. Describe the usefulness of standardized outcome measures for documenting participation.


3. Describe the process of conducting an interview to obtain information pertaining to level of participation, social history, and general health status.


4. Document these components with accuracy and specificity.


Chapter 5 discussed documentation of reason for referral as it pertains to medical information and health condition. A second important part of documenting reason for referral relates to social history and participation (Figure 6-1). This addresses both environmental and contextual factors and describes the ability of a patient or client to perform the specific functions pertinent to his or her everyday life. How is the current condition affecting the individual’s life? What are the patient’s current life roles, and is the patient able to perform his or her roles as a husband/wife or father/mother? What is the person’s home and/or work environment, and how does it affect his or her ability to function independently? Can he or she work in either a paid or volunteer position? Is he or she able to engage in social and recreational activities?


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FIGURE 6-1 This chapter discusses documentation pertaining to Restrictions in Participation, as well as Contextual Factors (environmental and personal), based on the International Classification of Functioning, Disability and Health framework.

How is this information best obtained? The first step is to obtain as much information as possible from the patient’s medical record. This minimizes repetitive interviewing of the patient and helps prepare the therapist to better organize the examination. The second step is to spend time talking with, and listening to, patients. Although time is often limited in rehabilitation settings, physical therapists (PTs) can prevent many missed diagnoses and develop an appropriate plan of care from the onset if they spend an adequate amount of time gathering pertinent information about their patients. Simply asking some basic questions can provide the therapist with valuable information about the problems affecting a patient’s life. Indeed, asking these questions early often saves time because it enables the therapist to be more selective in his or her examination.


Assessment of participation clearly sets the rehabilitation professional apart from many other medical professionals. Medical doctors, for example, spend much of their time determining an accurate health condition and relating the patient’s impairments to that condition. Conversely, PTs should (and often do) spend a significant amount of their time at the other end of the disability spectrum—focusing on the interrelationship between participation and activities and between activities and impairments. Obtaining this information that encompasses a patient’s specific life roles provides the foundation for shaping the rehabilitation process. As noted in Chapter 1, it is the starting point for the process of rehabilitation.



Components of Documenting Participation and Social History


The Guide to Physical Therapist Practice (APTA, 2001) outlines various aspects of patient history taking that are part of the examination process. Table 6-1 details aspects of the patient history that can be categorized in this section of a note. Depending on the patient’s problems and length of the evaluation, each component can be documented independently (Case Examples 6-1 and 6-2) or generally combined (Case Example 6-3). The degree to which the headings Participation and Social History are used may differ depending on the institution and patient population. In addition, other information can be included here. General Health Status is often included in this section and includes information pertaining to the patient’s overall health and wellness. This information could include physical and psychological functioning, level of fitness, and behavioral health risks (e.g., history of smoking) or growth and development (in pediatric cases, e.g., date at which child began sitting or walking). Case Examples 6-1 through 6-3 provide sample documentation of participation and social history in different clinical settings (also see Case Examples 4-1 to 4-4).



CASE EXAMPLE 6-1


Setting: Outpatient


Name: Rick Quincy  D.O.B.: 12/29/63  Date of Eval.: 6/14/08









CASE EXAMPLE 6-2


Setting: Inpatient Acute Care


Name: Lisa Jeter  D.O.B.: 5/20/59  Date of Eval.: 12/10/09








CASE EXAMPLE 6-3


Setting: Outpatient


Name: Anita Garcia  D.O.B.: 1/3/90  Date of Eval.: 1/10/09




The focus of documentation of participation and social history varies for different patients and in different settings. Certainly, the primary concern for patients who are very sick in the hospital is working toward attainment of an independent functional status, such as their ability to dress themselves and shower. In fact, in a hospital setting, documentation of a patient’s work status, home situation and environment, and general health status often refers to what the patient was doing before being admitted to the hospital (What was his or her job? What sports and recreational activities did he or she enjoy participating in?). When the patient is receiving outpatient or home-based services, the focus of documentation should reflect current issues (Is the patient currently working and, if so, at what functional level? Can he or she return to recreational sports?).



PARTICIPATION


Measurement of participation encompasses a person’s involvement in community, leisure, and social activities, which are essential to an individual’s quality of life. Providing accurate and reasonable documentation about a person’s ability to participate in these activities is critical, particularly to justify services for many patients who may appear “high functioning.”


If a patient or client is working or has recently stopped working because of an injury or illness, the nature of the work should be documented in sufficient detail. Such notations typically include a listing or description of the tasks or activities the patient performs in a typical day (e.g., typing, writing, lifting) and any unique requirements to the patient’s job (e.g., “lifting >50 lb,” “standing for >1 hr at a time”). The therapist should also document here any volunteer work in which the patient is or was participating (e.g., “volunteers at hospital transporting patients 1 ×/wk”) and any of the patient’s social activities, if this information is pertinent to rehabilitation.


It is important to contrast current level of functioning and participation with prior level of functioning and participation. Prior functional status refers to the degree of functional skill of a patient in self-care, leisure, and social activities before the onset of the current medical diagnosis or health condition. Determination of prior functional status is particularly relevant for older patients or those with previous medical conditions. Such patients may not have been independent in all activities before the onset of their current condition; they may have had some limitations as a result of other medical conditions or problems related to their current medical condition. For example, a patient who has had a stroke may have had a preexisting condition of emphysema. This may have limited the patient’s walking distance as a result of pulmonary limitations even before the stroke.


The goal of therapy is often to restore the patient to at least the level of prior functioning. Sometimes the goal is to restore the patient to a higher level of functioning, as in the case of a patient with arthritis who elects to have a total knee replacement. Because that patient’s functional abilities may have been significantly limited by the arthritis, the knee replacement may enable the patient to improve to a significantly higher functional level.



SOCIAL HISTORY


The PT documents a wide range of information pertaining to the patient’s home and living situation under this heading, often including details about the type of home, the number of floors, and the number and type of stairs. If a patient uses certain medical equipment, such as a wheelchair or a raised toilet seat, this is reported here. The PT should describe the equipment and how it is used in sufficient detail. (Example: “Pt. uses a lightweight wheelchair, with gel cushion and swing-away leg rests, for mobility within the home.”)


Descriptions of the patient’s family and caregiver resources are also components of the home environment. Cultural beliefs and behaviors, as they are relevant to the rehabilitation process, should also be included here. However, specific details about a patient’s personal life that are not pertinent to his or her current medical condition or reason for referral should not be included in patient documentation. For example, it would rarely be necessary to refer to a patient as “divorced” or to identify a person’s specific religious affiliation unless it affected his or her evaluation and treatment in some way.

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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Documenting Reason for Referral: Participation and Social History,

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