Professional Documents
Culture Documents
PURPOSES OF DOCUMENTATION
Patient care notes record what the therapist does to manage the individual patients case. Ensure that the rights of the therapist and the patient are protected
SOAP
S subjective O objective A assessment P plan
Prognosis
Plan of care
TYPES OF NOTES
Initial Note/Initial Evaluation written after the first examination and evaluation and documents the examination, evaluation, diagnosis, prognosis, and plan of care Progress/Interim Notes written periodically, reporting the results of re-examination and re-evaluation and changes in the prognosis and plan of care, as needed Discharge notes/summary written at the time that therapy is discontinued, after a final examination and evaluation are performed; addresses the results of the final examination and evaluation, the outcomes and goals achieved, a summary of the interventions received, and the final disposition of the patient
GUIDELINES IN CHARTING
Accuracy Brevity Clarity
Example Brief Pt. amb 10 ft in // bars indep. But required min assist of 1 to turn around in // bars. Sit stand from w/c indep. Using // bars for support. Long and windy Once the patient wheeled to the // bars and positioned himself in front of the // bars, he locked his w/c, raised the foot plates, and scooted forward from the seat of the chair. He then gripped the // bars with his hands and on the count of 3 was able to pull himself up to a standing position without any assist, from the therapist. Once standing, he was able to ambulate by positioning his arms forward and then taking steps. He could lead with either right or left foot. Upon turning in the // bars, he was unable to let go with one arm to pivot his body around. Therapist had to give some support until the patient was turned around and both arms were back on the // bars.
Example Incorrect Pt. stated she lived alone. Describes 5 steps s hand railing of her 1story house. Denied previous use of assist. Device Correct States lives alone. Describes 5 steps s hand railing at entry of her 1-story house. Denies previous use of assist. device.
Example
PUNCTUATION
Hyphen (-) Should be avoided in notes because they can be confused with the minus signs used in mm grades or negatives (as in SLR on (R)) Exception is in ROM Semicolon (;) Instead of overusing states in the subjective part of the note, a semicolon can be used to connect two related statements. Colon (:) Can be used instead of is Ex: Instead of AROM (R) shoulder flexion is 0-90, you could say AROM (R) shoulder flexion: 0-90 Example Wordy states position of comfort for sleep is on (R) side. States pain does not awaken pt. at night. Brief states position of comfort for sleep is on (R) side; pain does not awaken pt. at night.
Correcting errors Makes it look as if the health professional is trying to cover up malpractice
Put a line through the error, write the date and initial it above the error
Signing Your Notes Should sign every entry that you make into the medical record. All notes should be signed with your legal signature (your last name and legal first name or initials.) No nickname should be used. Initials should follow your name indicating your status as a therapist or therapist assistant
Referring to yourself
Notes discuss the patient and not the therapist Ex: INCORRECT: I helped this patient transfer c min. assist. from his w.c to the plinth CORRECT: Pt. transferred c min assist, w/cplinth Blank or Empty Lines Empty lines should not be left between one entry and another, nor should empty lines be left within a single entry Empty lines are areas in which another person could falsify I nformation already charted. Writing orders in a Chart FORMAT: date/time/order v.o. physicians name/therapists signature, PT