DEFENSIVE DOCUMENTATION
WHY DO WE NEED DOCUMENTATION?
• Provide a record of interventions and associated
outcomes
• Provide a record of progress or the lack of
• Give a rationale for chosen interventions
• Substantiate the charges
• Support the need for skilled therapy services
• Serve as a tool for research
• Provide a legal record of care
FORMATS AND STYLES
• Electronic: The trend is moving toward electronic
documentation. Many different programs exists at this time
• Hand written:
SOAP notes
Flow sheets
Errors
• Cross out with a straight line
• Write error above
• Write the correct data
• Initial
• Date
• Write an addendum if necessary ( electronic
documentation will usually require an addendum)
Dates and Time
Always date your entries and record time in and out
Signatures
Always sign or initial your entries
Abbreviations
Erickson Appendix; pgs. 155-160
Subjective
• Everything the patient tells you in connection with his/her
condition throughout the treatment.
• Pain rating
• Sleep
• Overall feeling
• Be discreet with information that is not directly related to the
treatment.
Objective
• Everything you do with the patient during the treatment
• Measurements
• Settings and time for modalities
• Distance
• Assistance required
• Repetitions and number of sets
• Vital signs
• Other
: behavior, mental status, compliance
Assessment
• Pulls it all together
• Explains what it all means
• Provides the reason for continuing treatment
• Explains why skilled PT intervention is needed
• Summarizes the Subjective and Objective and relates them to the
treatment goals
• This is the section 3rd party payers are most interested in
Assessment continued
• Express your professional opinion
• How is the patient improving?
• Will the patient benefit from continuing PT intervention?
• Should - Could – Would
• BUZZ WORDS/ PHRASES:
As evidenced by…..
Should benefit from……
Seemed comfortable with….. as seen in increase ability
to……
• Patient is progressing well toward…… STG/LTG #........
• Patient has reached goal #.........at this time
• Pt seemed to have difficulty with ………
• Pt seemed to have suffered a set back as shown by………….
• Pt seemed unable to progress with exercises today due to………
Plan
• Should relate to the P.O.C.
• What will you address on the next visit?
• What goals are going to be addressed?
• Will the patient need a re-assessement?
• What and why will you communicate with the evaluating PT?
• Why are you planning a particular intervention?
• The PLAN serves as a reminder for you or the therapist treating
the patient next