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ProPrac Documenting

Documentation & the Law

QuestionAnswer
If it's not documented... It didn't happen according to a court of law!
Part of our legal duty... We're required by legal, professional & business ethical standards to record clinically pertinent hx, exam, eval, & intervention related info about pts & maintain info in the form of pt rx records
KS Rules & Regs: What should the PT record contain? Be legible; ID pt/client; Contain eval, diagnosis, plan of care, & treatment & discharge plan
What should be included in documentation? Eval; Re-eval/Re-exam; Progress note/SOAP for each visit; D/C summary
Evaluation Includes exam which must include: pt hx, systems review, tests & measures; If anything not documented, must document why they weren't!
Why should progress notes all look somewhat different? Repetitive documentation doesn't show need for skilled intervention or progress
Re-Evaluation Also considered re-examination; needs to be done when: the plan of rx needs to be modified or different interventions need to be attempted
D/C Summary Summary of all the care a pt received during the episode of care; should include: pt's initial status, d/c status, treatments received, outcomes
What is a discharge summary used for? Justify continuance or discontinuance of services; Some plaintiffs may allege improper d/c from TP & this will support/defend this claim
WNL & WFL...good or bad? Commonly seen with regard to ROM/MMT; these are assessments, NOT objective measurements; Do NOT use in "O" of SOAP Note!
Illegible Notation Can't read documentation to continue POC; Some clinics now use dictation & computerized documentation to offset this problem
Improper ID of Pt Every page of pt's record must have: pt's full name written in ink/stamp & DOB; always write pt's name on all pages before documenting to avoid entry in wrong chart!
When writing the date what should be included with each new entry? Day, Month, Year
What sort of recording/writing instruments shouldn't be used? Pencils; Erasable ink; Felt-tipped pens
What to do when ink runs out in middle of note? Include (Note: original pen ran out of ink. JDM, PT)
Abbreviations Each facility should have/develop list of acceptable abbreviations; include "key" on back side of documentation for ease of clarification
Spoilation of Evidence Intentional destruction, mutilation, alteration, or concealment of evidence
What is a Valcin jury? Jury instructed to presume that the missing documentation would favor the plaintiff
How to do a corrective note One line marked thru the incorrect documentation & labeled "incorrect entry" or "error", dated, & PT signature/initials; No write-overs/scratch-outs/white-out
Incident Reports Document occurrence out of the ordinary/not expected; May/may not have negative outcome; Created in anticipation of litigation
More Incident Reports DON'T document in pt record that one was filed as this then allows plaintiff attorney to request it; complete fully & immediately; Can be used by defense but if not mentioned in pt's record not used by plaintiff's attorney
What does a HC provider have to do in regards to HIPPA? Notify pt about privacy & how info can be used; Adopt & implement privacy procedures; Train employees in privacy procedures; Designate someone responsible for privacy procedures & enforcement; Secure pt records
Some Medicare Requirements Time in/out; Total rx mins; Total timed mins; Total untimed mins
Created by: Jenica Moore Jenica Moore on 2013-03-20



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