Foundation of Physical Therapy Healthcare Process (Part 3)
January 5th 2008 07:17
Documentation
“The documentation of patient care is an important component of the written record maintained for each patient (Pierson, 1999)”. Therefore, before we discuss the techniques in history taking, physical examination, and physical therapy management, we need to be familiarized with the methods of documentation.
In the 1960s, Lawrence Weed developed the concept of problem-oriented medical record (POMR). Since then, this system of documentation has been widely used all around the world. The POMR revolves around the discussion of patient conditions based on a list of problems that a patient is exhibiting, a database, and a series of progress notes from the first time a patient was seen (initial evaluation), to the regular re-evaluation of patient, and until the patient has been discharged from our care (discharge notes).
According to Pierson, POMR proves to be advantageous since it warrants higher quality of patient care, better communication among healthcare providers, and better decision about the patient’s treatment. Patient information and the plan are contained in the status notes, which are written in the following format: subjective, objective, assessment, and plan information (SOAP).
The POMR has four phases which include the formation of a database (current and past information), development of specific problem list, identification of specific treatment plan, and assessment of the effectiveness of the treatment plan.
We have to remember that the SOAP notes should contain important and relevant information about the patient. They should accurately tell the readers about the condition of patients and if there are any changes observed from the patient (either progressive or regressive). They should also tell the exact dosage and frequency of treatments administered to the patient. And most of all entries in our documentation must be written with credibility.
Here are some ways to improve our documentation (Pierson, 1999):
• Avoid general statements and provide specific, clarifying information.
• Use objective, tangible, and measurable statements or goals.
• Be complete with your statements; record the significant or important incidents or information about the patient’s condition, progress, or response to treatment.
• Provide continuity with your status (progress) notes. Be certain to indicate why or how you reached a particular decision about the care or treatment you provided, particularly if it deviated from the usual, acceptable care or treatment.
• Identify that you informed the patient of the treatment plan he/she was to receive and its potential risks or hazards; that this information was understood by the patient; and the patient consented to the treatment.
• Be prompt and timely with your entries and be certain your writing is legible, including your signature and professional staff designation.
• Be certain there are no empty or open lines between entries and that there are no open spaces within notes.
• Avoid omissions, such as date of initial or subsequent treatments, change in treatment, or a discharge summary.
Occasionally it may be necessary to correct an entry. However, we have to observe the proper way in correcting a wrong entry. This will help us avoid accusations of tampering or changing any entry for self-serving reasons.
How do we properly correct wrong entries? We draw a single line through the inaccurate information, being certain the material remains legible. We date and initial the correction, and add a note in the margin stating why the correction was necessary. Then, we enter the corrected statement in the chronological sequence of the record, and should be certain it is clear which entry the correction replaces.
To Be Continued...
“The documentation of patient care is an important component of the written record maintained for each patient (Pierson, 1999)”. Therefore, before we discuss the techniques in history taking, physical examination, and physical therapy management, we need to be familiarized with the methods of documentation.
In the 1960s, Lawrence Weed developed the concept of problem-oriented medical record (POMR). Since then, this system of documentation has been widely used all around the world. The POMR revolves around the discussion of patient conditions based on a list of problems that a patient is exhibiting, a database, and a series of progress notes from the first time a patient was seen (initial evaluation), to the regular re-evaluation of patient, and until the patient has been discharged from our care (discharge notes).
According to Pierson, POMR proves to be advantageous since it warrants higher quality of patient care, better communication among healthcare providers, and better decision about the patient’s treatment. Patient information and the plan are contained in the status notes, which are written in the following format: subjective, objective, assessment, and plan information (SOAP).
The POMR has four phases which include the formation of a database (current and past information), development of specific problem list, identification of specific treatment plan, and assessment of the effectiveness of the treatment plan.
We have to remember that the SOAP notes should contain important and relevant information about the patient. They should accurately tell the readers about the condition of patients and if there are any changes observed from the patient (either progressive or regressive). They should also tell the exact dosage and frequency of treatments administered to the patient. And most of all entries in our documentation must be written with credibility.
Here are some ways to improve our documentation (Pierson, 1999):
• Avoid general statements and provide specific, clarifying information.
• Use objective, tangible, and measurable statements or goals.
• Be complete with your statements; record the significant or important incidents or information about the patient’s condition, progress, or response to treatment.
• Provide continuity with your status (progress) notes. Be certain to indicate why or how you reached a particular decision about the care or treatment you provided, particularly if it deviated from the usual, acceptable care or treatment.
• Identify that you informed the patient of the treatment plan he/she was to receive and its potential risks or hazards; that this information was understood by the patient; and the patient consented to the treatment.
• Be prompt and timely with your entries and be certain your writing is legible, including your signature and professional staff designation.
• Be certain there are no empty or open lines between entries and that there are no open spaces within notes.
• Avoid omissions, such as date of initial or subsequent treatments, change in treatment, or a discharge summary.
Occasionally it may be necessary to correct an entry. However, we have to observe the proper way in correcting a wrong entry. This will help us avoid accusations of tampering or changing any entry for self-serving reasons.
How do we properly correct wrong entries? We draw a single line through the inaccurate information, being certain the material remains legible. We date and initial the correction, and add a note in the margin stating why the correction was necessary. Then, we enter the corrected statement in the chronological sequence of the record, and should be certain it is clear which entry the correction replaces.
To Be Continued...
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