Documentation & the Law
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| If it's not documented... | It didn't happen according to a court of law!
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| 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
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| KS Rules & Regs: What should the PT record contain? | Be legible; ID pt/client; Contain eval, diagnosis, plan of care, & treatment & discharge plan
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| What should be included in documentation? | Eval; Re-eval/Re-exam; Progress note/SOAP for each visit; D/C summary
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| Evaluation | Includes exam which must include: pt hx, systems review, tests & measures; If anything not documented, must document why they weren't!
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| Why should progress notes all look somewhat different? | Repetitive documentation doesn't show need for skilled intervention or progress
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| 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
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| 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
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| 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
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| 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!
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| Illegible Notation | Can't read documentation to continue POC; Some clinics now use dictation & computerized documentation to offset this problem
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| 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!
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| When writing the date what should be included with each new entry? | Day, Month, Year
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| What sort of recording/writing instruments shouldn't be used? | Pencils; Erasable ink; Felt-tipped pens
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| What to do when ink runs out in middle of note? | Include (Note: original pen ran out of ink. JDM, PT)
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| Abbreviations | Each facility should have/develop list of acceptable abbreviations; include "key" on back side of documentation for ease of clarification
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| Spoilation of Evidence | Intentional destruction, mutilation, alteration, or concealment of evidence
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| What is a Valcin jury? | Jury instructed to presume that the missing documentation would favor the plaintiff
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| 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
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| Incident Reports | Document occurrence out of the ordinary/not expected; May/may not have negative outcome; Created in anticipation of litigation
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| 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
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| 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
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| Some Medicare Requirements | Time in/out; Total rx mins; Total timed mins; Total untimed mins
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