Essentials of Documentation



Essentials of Documentation



LEARNING OBJECTIVES


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


1. Discuss the history of the medical record and documentation.


2. Identify the four basic types of physical therapy notes.


3. List the different purposes that documentation serves.


4. Discuss the pros and cons of different documentation formats.


5. Discuss the importance of using standardized assessments as part of documentation, and describe the four types of standardized measures commonly used.


6. Describe strategies for concise documentation.


7. Appropriately use and interpret common rehabilitation and medical abbreviations.


8. Use people-first language in written and oral communication.



Documentation: An Overview


Physical therapists (PTs) and physical therapist assistants (PTAs) often view documentation as an onerous chore. At best, it is considered a necessary evil, to be accomplished as quickly and painlessly as possible. At worst, it is a conspiracy by bureaucrats to waste therapists’ time and limit patient access to essential services. Despite this view, the modern medical record is one of the most important achievements in the development of twentieth-century medicine. At the beginning of the twentieth century, the notion of a patient-centered chart that stayed with the patient was almost unheard of. Instead, records were kept by individual practitioners, and often the records were haphazard. The development of a comprehensive patient-centered chart, professionally written and clearly organized, enabled direct improvements in patient care by promoting accurate and timely communication among professionals. It also allowed improvements in patient care indirectly by facilitating better review of the process. The medical chart is the collector and organizer of the primary data for clinical research. It is also an essential teaching device. Students and novice clinicians learn about how to provide patient care by reading the documentation written by expert clinicians. It is doubtful that health care would have reached the present level of accomplishment without the changes in documentation over the past century. Moreover, future improvements in patient care will be associated with, and enabled by, changes in the way the process is documented. Documentation is therefore a dynamic phenomenon, ever-changing. The dominant formats can be expected to adapt to the changes in health care.


Of course, changes in health care have occurred not just in the clinical domain, but also in the economic and social domains. The United States is in the midst of a period in which fundamental changes are occurring in the way in which health care is financed and compensated. The entire third-party payer system is likely to be overhauled in the near future, and payers may move away from reimbursing procedures (fee-for-service) and toward reimbursing outcomes. In other words, practitioners must clearly justify the treatment they are implementing in terms of the outcomes that will be achieved.


Despite its importance, documentation is often viewed negatively by therapists for at least two reasons. 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. Thus students and therapists must spend dedicated, focused time to learn the “skill” of documentation. Skill develops with practice, practice, and more practice.


Skill in documentation is the hallmark of a professional approach to therapy and is one of the characteristics that distinguishes a professional from a technician. 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.


In this chapter, some of the essential aspects of documentation are addressed. Different classifications and formats for physical therapy documentation are presented, as well as critical aspects of information that should be included and the manner in which they should be reported.



Types of Notes


Four basic types of medical record documentation exist: the initial evaluation, treatment notes, reexamination or progress notes, and the discharge summary. The following list is adapted from Guidelines: Physical Therapy Documentation of Patient/Client Management (APTA, 2008).


The main aspects of this book focus on documentation of the initial evaluation components (see Chapters 5 through 11). Special considerations for writing treatment notes and progress notes are specifically covered in Chapter 12. Documentation of discharge summary and other types of documentation are discussed in Chapter 13.




TREATMENT NOTES (WRITTEN BY PHYSICAL THERAPIST OR PHYSICAL THERAPIST ASSISTANT) FOR EACH THERAPY SESSION







Purposes of Note Writing


PT documentation serves many purposes. These include communication with other professionals, clinical decision making, and creation of a legal record of PT management of a patient.







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. In these cases, PTs, PTAs, and students should use the format in general use within the institution. 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.



NARRATIVE FORMAT


The simplest form of documentation recounts what happened in a therapist-patient encounter. 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. 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). Furthermore, if information is not included it is assumed it was not tested, whereas the writer may have inadvertently omitted the testing information. Thus therapists must take particular care to be comprehensive in their documentation to minimize inconsistencies and maximize accuracy.



SOAP FORMAT


The SOAP note is a highly structured documentation format. It was developed in the 1960s at the University of Vermont by Dr. Lawrence Weed as part of the problem-oriented medical record (POMR). In this type of medical record, each patient chart is headed by a numbered list of patient 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 and then write a note using SOAP format. The SOAP format requires the practitioner to enter information in the order of the acronym’s initials: subjective objective assessment plan (see Chapter 12 for more detailed information on writing SOAP notes).


The POMR was not widely adopted, perhaps because it was ahead of its time. Interestingly, however, the SOAP format did catch on and is now widely used by different professionals, despite the fact that it is no longer connected to its parent concept, the POMR. A major advantage of the SOAP format is its widespread acceptance and the resulting familiarity with the format. On the plus side, it emphasizes clear, complete, and well-organized reporting of findings with a natural progression from data collection to assessment to plan. On the other hand, it has generally been associated with an overly brief and concise style, including extensive use of abbreviations and acronyms, a style that is often difficult for nonprofessionals to interpret. On a more substantive note, Delitto and Snyder-Mackler (1995) have commented that 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 (See Chapter 13).



FUNCTIONAL OUTCOME REPORT FORMAT


The functional outcome report (FOR) format is a relatively new documentation format. It was developed in the 1990s as changes in the economics of health care led 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 the patient. 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.


Several authors have presented frameworks for FOR documentation. The most well-developed and structured format is that of Stewart and Abeln (1993). Their book has played a major role in promoting the idea that documentation should be focused on functional outcomes, and many of their ideas have been adapted in developing the format presented in this book. Their format was not adopted for this text for two reasons. First, the format is too highly structured and difficult to adapt to different clinical contexts. Second, their book and format are entirely focused on orthopedic physical therapy and thus translation into other contexts is difficult. Nevertheless, this book is highly recommended especially because of its strong emphasis on the need for FOR documentation.



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.


Documentation takes many forms, including written reports, standardized assessments, graphs and tables, and photographs and drawings.


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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Essentials of Documentation

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