Ch 01: Why before How: The Rationale behind Medical Documentation

“The secret of getting ahead is getting started.”  –-  Mark Twain

Thus far in our PTA Program, your exposure to medical documentation has been limited to something we referred to as the SOAP note. We used that type of note to document what you did with your ‘patient’ during your lab practicals. At this point, you may remember little more than what each letter stood for. Now, however, it is time to develop a deeper understanding of both medical documentation and the SOAP note. Let’s address the former item first.

To do so, we must answer the following questions:

  • Why do we need to spend so much time and energy regarding medical documentation?
  • Wouldn’t the patient do better if we spent more time treating them rather than spending time with documentation?

Both are valid questions. You can think of it like this:

Say your car is acting up and you drop your car off at the mechanic’s shop. When you come back to pick it up, you are given a bill for $400.00: $200.00 for parts; $200.00 for labor.

You might be thinking, ‘Wow, did the repairs really need to cost that much? Just what was wrong with my car anyway?” For you to believe that paying the bill makes sense, knowing ‘why’ it cost that much would help.

For example:

How did the mechanic decide what was wrong?

Why were certain parts replaced, but not others?

Why did my car ‘breakdown’ to begin with?

Will it happen again?

What can I do to avoid it happening again?

You get the idea.
 

Well, one way you can be sure that what was done needed to be done is for the mechanic’s bill to be formatted such that it explains:
  1. How your car was diagnosed:
    1. What tests were performed and why.
    2. What the results of these tests meant.
    3. How those diagnostic test results were related to your car’s performance.
  2. How the parts that were replaced were determined to be faulty and part of the problem…. and thus, need to be replaced.
  3. Why the labor cost as much as it did (why it took as long as it did to fix the car).
  4. If there is anything you can do to avoid needing to have this type of repair again in the future.

 

If the bill did include such items, you probably would feel better about paying it because:

  • You could see the logic that was used to make the repairs: That the repairs were NOT based on hunches or guesses, but facts.
  • You would be more enlightened (you would have a greater understanding) about your car and its upkeep.
  • That your car was tested following the repairs to make sure the problem(s) were indeed fixed.
  • If your car developed problems in the future, you could take this type of a bill to the mechanic so that if a different mechanic were to look at your car, they would know its history.
  • You get the idea.

 

Medical documentation addresses the issues from this example.

  1. It allows us to learn the history of the patient: both the recent as well as the prior history.
  2. We learn what specifically brought the patient to the healthcare system as well as to PT specifically.
  3. We learn what tests the PT performed during the initial evaluation, what those tests meant and how they helped determine the PT POC.
  4. We learn what is being done in the session to help the patient and why it is being done.
  5. We leant how the patient is responding to the treatment and what problems still exist for the patient.
  6. We learn what may be helpful in the next treatment session.
  7. Other people involved in the care of the patient can also review the documentation to learn about the patient. That may be the doctor, another therapist, a discharge planner or the insurance company – who will be reviewing the note to see if the treatment made sense and is eligible to be reimbursed.

 

REFLECTION ACTIVITY 1: DOCUMENTATION EXERCISE 1.    (DOC Ex 1).

  1. If you were the patient, what types of information would you want included in the medical record? Why?
  2. If you were about to work with a patient you had not seen before, what types of information would be important to know?
  3. If you were the patient’s doctor, what might you want to know about your patient’s
    performance during PT?
  4. If you were the insurance company payment specialist determining if you should pay for that day’s treatment, what types of information in the note would you be looking for?





					
		
					

						

							

								
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This work (An Introduction to Medical Documentation for the Physical Therapist Assistant by jmm49 and Dan Dandy PT, DPT, ACCE) is free of known copyright restrictions.
							

														

								
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