4 Chapter 04: GUIDELINES FOR EFFECTIVE DOCUMENTATION: ACCURACY, BREVITY, CLARITY

1. Medical documentation has three general purposes:

1. 1. It records the components of patient care
   2. It provides the basis for reimbursement for the patient care
   3. 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.

2. 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”.

3. 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.

2. CLINICAL TANGENT:

1. 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 the amount of time required to reach that level. Prognosis is typically not a separate documentation element, but the components are included as part of the plan of care.

• • PLAN OF CARE (POC) Typically stated in general terms. It includes:
    • Goals: These may be general of presented as Short-Term Goals (STGs) and Long-Term Goals (LTGs). This depends on the setting. Some settings the patient’s length of stay may only be for a few visits; only general (LTG) goals are needed.
    • A list of proposed interventions
    • The proposed frequency and duration
    • The discharge (DC) plans.
    • It may also include (based on the EMR software or preference of the clinic site) documentation of the assessment of the data collected in the examination as well as the identification of problems pertinent to patient/client management: An “Impairment List”.

2. The Discharge (DC) Summary. This is a document that the PT creates that summaries the services (treatment interventions) provided to the patient during their episode of care (length of time the patient was under the care of the therapist). It includes objective measures (metrics) of the patient’s progress during their course of treatment as well as any residual impairments. It will note the patient’s status related to each of the goals created during the initial evaluation (if the goal was met or not…and if not, why.) Finally, it will include recommendations for the patient. The PTA can collect the subjective report and objective data for a DC summary, but, per the PTA Practice Act, cannot “interpret” it in terms of creating or changing a treatment plan or discharging a patient. It is the PT, not PTA, that will write the DC note.
   

ACCURACY

“Fast is fine, but accuracy is everything.” — Wyatt Earp

“I was gratified to be able to answer promptly, and I did. I said I didn’t know.”  — Mark Twain

At this point, you may be thinking that accuracy is about correct spelling or punctuation…and you would be right; it is.  However, accuracy is about much  more. It is about how we enter, or chose not to enter, our patient-related information.

Can you think of any reasons why you might enter an inaccurate distance for a patient’s ambulation?   Perhaps you didn’t think the exact distance mattered all that much (however, to a discharge planner reviewing each note to assess a patient’s progress, every foot matters).  Perhaps you just weren’t sure of the distance and thought guessing would be okay.  However, an inaccuracy in your recorded distances could lead to a delay in discharging the patient…or an early discharge, before the patient was really ready.  When in doubt, please follow Mark Twain’s advice and ask.   That applies to many aspects of being a student-therapist…but more on that later.

Certainly there is another side to documentation inaccuracies.  One that is more deliberate. One that is done with forethought.  Can you see where this is headed?  We are referring to times of minimizing or exaggerating a patient’s performance in our documentation as a way of influencing their care.  Even if done with the most altruistic of motives, intentionally entering inaccurate information is fraudulent; something that can, amongst other things,  cause you to lose the very license you are working so hard to earn.

Common Sources of Errors:

• Incorrect facts (for example, guessing how far a patient ambulated, rather than entering the correct distance).
• The use of incorrect, inaccurate or vague language. Poor word choice can be misleading or misinterpreted.
• Errors can be related to grammatical mistakes with spelling, syntax or punctuation. Grammatical mistakes can be confusing and are unprofessional.

In a gunfight as well as in a clinic, we need to hurry slowly.  Accuracy is everything.

BREVITY

“If it takes a lot of words to say what you have in mind, give it more thought.”  — Dennis Roth

It is hard to add much to that quote, except: Yes indeed.   Many of us know someone who speaks before they think.  They rarely filter their thoughts first; if they have a thought, they share it.  While this may be a charming attribute and it certainly makes them fun to be around, when this approach is applied to documentation, the result is often disastrous.  It can make finding the relevant information a task that requires much more time (your time) than you have to give.

In situations where the note rambles on in a disorganized fashion, there is a great temptation to just skim the note and hope to find what you are looking for.  This, of course, is never a good idea as it can cause us to miss valuable information.  The solution is for all of us to be complete and thorough, but concise with our documentation. To that end:

1. Abbreviations:
   • When allowed, the use a abbreviations can help shorten and tighten up a note.  Not all clinics/facilities allow for abbreviations.  For those that do, they will have a list of approved abbreviations that you can use. You will need to review that ‘approved abbreviation list’ to make sure the abbreviations you like to use in your documentation are listed. If not, do NOT use it.
   • You may be wondering, ‘Since I am so very creative, can I make up my own abbreviations?’    Glad you asked.  No. We do not make up our own abbreviations. No matter how clever it may be, do not make up abbreviations.
   • You now may be wondering if there are any universally recognized abbreviations that are safe to use. The following abbreviations are typically accepted at every clinic site.  Please commit them to memory.  If you are unsure of their meaning, please refer to your Medical Vocabulary text or check in with your instructor.

TERMS 01: PLEASE PUT THE FOLLOWING ABBREVIATIONS AND MEDICAL TERMS TO MEMORY:

Strange, but true:

You might think that we, as therapists, should be able to abbreviate our patients as ‘pt’.    For example: The pt presents with c/o neck pain.

Unfortunately, we cannot.  Can you think of a reason why not?   Well, it turns out that there are other medical terms that could also be abbreviated as pt.

For example:  PT or pt could mean:    Pro Time (A blood test to assess coagulation time).  Physical Therapy.  Physical Therapist. Point. And so on.

If a doctor writes “pt” and meant pro time, but the nurse thought the doctor meant physical therapy, we could wind up with a patient in the gym that should not be there. To avoid such errors, errors that could be disastrous, abbreviations are only used from a facility’s approved abbreviation list.

2. Avoid run-on sentences:  

• Separate sentences or thoughts.
• Correctly use commas, semi-colons (used to join two related thoughts in one sentence) and colons (used to list items)
• Think before you write: Keep your notes focused.

3. Avoid Fluff

Sometimes clinicians, wanting to be thorough, document ‘e  v  e  r  y  t  h  i  n  g’   that occurred in a treatment session.  As we said earlier, this can cause those reading the note to skim through it searching for the information they need.  Let’s avoid the fluff by being thorough, but be focused, relevant and clear. More is not always better as in the example below.