At the completion of this chapter, the reader will be able to:
Discuss the various types of clinical documentation
Describe the normal sequence and order used in clinical documentation
Describe the purpose and importance of clinical documentation
Understand the common medical abbreviations used in healthcare
Understand how the legal requirements for cosigning by the supervising PT varies from state to state
Communication between the physical therapist (PT) and physical therapist assistant (PTA) is critical to ensure that the patient/client receives safe, appropriate, comprehensive, efficient, person-centered, and high-quality health-care services from initial evaluation through discharge.1 Together with verbal communication, written communication in the form of documentation forms the strong collaborative process that is essential between the PT and PTA.
Documentation in healthcare includes any entry into the patient/client record. As the record of client care, documentation also provides useful information for the other healthcare team members and for third-party payers. This documentation, considered a legal document, becomes a part of the patient’s medical record. As such, a clinician should never enter an endnote or sign an entry for someone else and should not ask someone else to perform such acts. Documentation is a mark of a clinician’s credibility, honesty, and intent, and any breaches of documentation rules can lead to charges of incompetence, negligent behavior, poor judgment, or prosecution.
Clinical documentation serves to:
Inform other healthcare providers as to the status of the patient
Describe what and how the patient performed
Provide necessary information for payer sources
Protect the clinician in case of patient complaint or injury
Whenever possible, documentation should follow the APTA’s Guidelines: Physical Therapy Documentation.*
An initial note is written after the first patient visit and documents the results from the examination, the subsequent evaluation, diagnosis, prognosis, and plan of care.
A progress note is written after each subsequent visit and documents the results of any reexamination and reevaluation and any change in the prognosis and plan of care as appropriate.
A discharge note is completed when therapy is discontinued and occurs after the final examination and evaluation are performed.
Several types of format are commonly used for writing notes:
Problem-oriented medical record (POMR): a traditional form of documentation developed in the 1960s by Dr. Lawrence Weed. The POMR has four phases: formation of a database which includes current and past information about the patient; development of a specific, current problem list which includes problems to be treated by various practitioners; identification of a specific treatment plan developed by each practitioner; and ...