- Medical documentation has three general purposes:
- It records the components of patient care
- It provides the basis for reimbursement for the patient care
- 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.
- 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”.
- 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.
CLINICAL TANGENT:While we will be looking at the SOAP note, as this is the format of documentation you will be using for your daily treatment notes, we should take a moment to mention three other important documents you will see often and need to know about. While we will review these in class in more depth, let’s name them now:
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”.
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.
- Your patient asks you how long you think they will be receiving PT treatments. Where in their medical record could you look to see what the projected length of treatment will be?
- After returning a patient to their room, a nurse asks if you wouldn’t mind doing a quick evaluation on a new patient – just to see if they need a walker to ambulate in their room or if a cane would work instead. How would you respond?
- Your CI asks you to complete the DC summary on your patient. How shall you respond? How can the PTA contribute to the DC summary?
- You are reading the PT notes on a patient you are about to treat for the first time. Where do you look to find their history (what caused their need for PT)? Where do you look to see if they are to receive any modalities during their treatment?
“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.
DOC Ex 4. What do you think?
Your patient has just ambulated the length of the gym with a rolling walker without pain or loss of balance. If the length of the gym is 100’ and, because you were too busy to measure the length of the gym you guessed at (and entered in the note) 50’, how might this impact patient?
- What if the gym length was only 25’ and you entered 50’?
- What is the best approach to take regarding this situation above?
What is it called when we document that the patient needs continued PT when, in fact, they have met their goals?
“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:
- 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:OOB BKA W/C PMH HPI C/O HOH THR UTI D/CDNR ECF EMG EKG ETOH HEP RA QD LUE TIA OA MI ORIF SOBWith: Without:
Twice daily: Three times daily:Know the definitions of: Acquiescence Indolent Compliant
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.
- 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.
Let’s have a go at tightening up this subjective entry.
Patient says that he had a bad night’s sleep because his roommate was really sick and was coughing all night and that this coughing kept him from getting any sleep or a good night’s rest so he is kinda extra tired this morning and may not be up to as much exercise.
- 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.1. Please put a line through the fluff and circle vague (unclear) terms or words.2. What questions would you want to ask the patient or therapist to get a clearer picture of the patient and the knee pain?3. Write a simple statement from what is left after you de-fluff and clean up this entry.
The patient reports that they did in fact have some increased knee pain while he was helping his spouse with cooking and baking activities last night. In the early evening they made spaghetti with meatballs, garlic bread and a tossed salad and then they baked some cookies for their grandchildren and a few neighbors who were to visit. So the knee pain wasn’t too bad, the patient says, while they were making the pasta, but later on, when it was time to bake the cookies, the discomfort began. It started mostly on the side of the knee, but then became most of the knee. During dinner it wasn’t really bad at all, but when washing the dishes, that pain on the side of the knee acted up a bit. They took some pain medication and it felt some better after that. Later they were nauseous, but not any more. They slept good, but did wake up a few times. Today, the pain isn’t too awful at all.
“The difference between the almost right word and the right word is really a large matter. ’tis the difference between the lightning bug and the lightning.” — Mark Twain
- Avoid Colloquialisms.
Colloquialisms refer to the use of jargon and informal vocabulary. We do not use this type of language in a medical document. While there are times when we will document ran exact word or phrase a patient offers us, we do so with “quotation marks” around the word or phrase…and we do so to illustrate a point or clarify a patient’s perspective. More on that to follow.Let’s begin to translate words or phrases from street-speak to medical-speak.
- Contractions: I’m = I am. Isn’t = Is not. Won’t = will not.
- Eliminate the use of “Got to”:
The term “Got to” is a very ambiguous phrase as may have multiple meanings.For example:
“I got to work today” may mean that the person went to work today. In other words, that they had the opportunity to go to work today.
However, it could also mean that they have no money and needs to go back to work to earn money.“I got to see my doctor today” could mean:I need to see my doctor – I feel ill and ‘need’ to see the doctor for some medicine to make me feel better.
However, it could also mean:
I was lucky enough to see my doctor earlier today – I had the experience of seeing my doctor.What do you think the “got – to’s” mean in this subjective entry:Patient offers that she got to see the doctor and that they also got to see the Physical Therapist for a re – evaluation or she isn’t going to get better.
- Slang Terms:
As we mentioned above, there are times when we need to or want to use the patient’s exact words even though the words may be in slang.
- Anytime we use a patient’s exact words, we use quotes.
There may also be times when we use paraphrasing as a means of shortening up an otherwise lengthy response from a patient.
Please translate these words or phrases from street-speak to medical-speak.
You ask your patient how they are feeling since their last treatment. They respond with a story to illustrate their improvement. During that story they may say something like,” Yes, you know, I do believe I am doing better since the other day when I was here…gee, ya know, I went to the store after I left here and didn’t even need to sit and rest. And, yes, I also sleep through the night without needing pain medication.”
You might document: The patient offered they are ‘doing well’ after last treatment. You might also add some detail…but more on that later.
Your patient reports that they have worked at a number of stores but the Chambersburg store is their home base.
You might document: The patient offers that the Chambersburg location of his company is his ‘home base’ for work activities.
Maybe your patient has been very ill, but today notes she is doing much better and feels as fit as a fiddle.
You could document: Patient states she feels “fit as a fiddle”.
Maybe your patient’s impaired LE circulation is getting worse and her feet are getting colder each day. Using their exact words illustrates their experience of the deteriorating circulatory condition:
Patient offers “my feet are as cold as the ice cubes in Santa’s refrigerator”.
Patient walked around the gym:
Patient having pain:
Patient go to do better in therapy or she won’t go home:
Patient still needs help getting around:
Patient needs like, some assistance when walking around:
Patient needs stronger legs:
- Avoid vague and ambiguous terms: Be descriptive and concrete. Eliminate words such as: good, bad, a lot, hard, things.
Please “un-ambiguate” the following entries:
- “It’s hard for patient to get all the exercises done without bad technique.”
- “The patient needed a lot of encouragement.”
- “The patient found it hard to walk around the gym”.
- “Patient’s pain was bad today”.
- “There are a lot of reasons why it is hard for the patient to get out of the chair”.
- “These documentation exercises are not too hard nor too bad”.