Chapter 04: GUIDELINES FOR EFFECTIVE DOCUMENTATION: ACCURACY, BREVITY, CLARITY
Chapter 04: GUIDELINES FOR EFFECTIVE DOCUMENTATION: ACCURACY, BREVITY, CLARITY
- Medical documentation has three general purposes:
- It records the components of patient care
- It provides the basis for reimbursement for the patient care
- It is a legal report of patient care: There is an old adage in the medical world worth remembering: “If it is not written, then it wasn’t done”. This refers to the role documentation has in the legal world.
- When you read any form of medical documentation, you will see that the patient is referred to as the “patient” or “client” – rather than by name. You will also see that when a clinician refers to themselves, they do so in the third person. So, if you were to refer to yourself in a note, you would do so in the third person: “This “therapist” or “this PTA”.
- Every entry into a medical document must have a date and a signature with credentials. As a student, you will sign your notes as SPTA. Student notes must always be co – signed by the supervising CI: a PT or PTA. However, each facility / clinic will have their own policy regarding where you sign: abide to the policy accordingly.
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CLINICAL TANGENT:
While we will be looking at the SOAP note, as this is the format of documentation you will be using for your daily treatment notes, we should take a moment to mention three other important documents you will see often and need to know about. While we will review these in class in more depth, let’s name them now:
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PHYSICAL THERAPY INITIAL EXAMINATION/EVALUATION:
- Documentation of the initial encounter is typically called the “initial examination,” the “initial examination/evaluation” or, most commonly, the “initial evaluation” (the “Initial eval”).
- Completion of the initial examination/ evaluation is typically completed by the PT in one visit but may occur over more than one visit.
- Only a PT can complete the Initial Exam/Evaluation: Not the PTA.
- In some instances, the patient is seen only for the evaluation – very limited treatment is provided on that visit. In other instances, after the eval, if the PT has their direct access license, treatment interventions may begin. – (More on this aspect of practice in class)
- Documentation elements for the initial examination/evaluation include the following:
- EXAMINATION: Includes data obtained from the history, systems review, and tests and measures.
- EVALUATION: Evaluation is a thought process that may not include formal documentation. It may include documentation of the assessment of the data collected in the examination and identification of problems pertinent to patient/client management.
- DIAGNOSIS: Indicates level of impairment, activity limitation and participation restriction determined by the physical therapist. May be indicated by selecting one or more preferred practice patterns from the Guide to Physical Therapist Practice.z
- PROGNOSIS: Provides documentation of the predicted level of improvement that might be attained through intervention and t