Documentation
HPR 451
Where does documentation fit into
the TR process?
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Assessment?
Planning??
Implementation???
Evaluation????
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Documentation – who needs it?
• TR/RT
– Basis for decisions, plan, results
• TR/RT supervisor, manager
– Evaluate TR/RT
– Pass information to other TR/RT staff
• Treatment team members
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Same as TR needs
Avoid duplication
Fill in gaps
Changes, problems, etc.
Documentation – who needs it?
• Insurers (include Medicare, Medicaid)
– Need information to justify payment
• Auditors, quality control personnel,
accreditation agencies (JC, CARF)
– What services are being provided
– Services being provide appropriately
• CEOs, Board of Directors, attorneys, etc.
– Allegations of errors or omissions up to and
including legal action
Basic Methods of Documentation
• Narrative – Chronological account of client
status, interventions performed and results
• Rarely used as a stand alone system at
present
– Doesn’t lend itself well to automation
– Tendency toward subjective, impacted by ‘style’
– Doesn’t necessarily allow for easy identification of
what is important (client’s condition changes)
versus what is not as important (no changes), can
lead to lengthy, repetitive entries
Narrative Advantages
• Flexible
• Good for information gathered over a long
period of time
• May combine well some other methods (flow
chart or graph for summary, narrative for
detail)
• Easy to train employees to use
• Always in chronological order
Problem Oriented Medical Record
(POMR)
• 5 parts
– Initial assessment (database) - chart information
plus assessment info
– Problem list – Client’s problems listed in
chronological order
– Initial Plan – one plan per problem
• Anticipated outcomes
• Plan for further data collection (more assessments)
• Patient care
Problem Oriented Medical Record
(POMR)
– Progress Notes – follow one of the following
specific formats
• SOAP – Subjective Objective Assessment Plan
• SOAPIE - + Intervention, Evaluation
• SOAPIER - + Revision
– Used for documentation, but only document the
sections you have something to report in
– Discharge Summary
• Review each problem on the problem list and report
whether resolved
Pluses of POMR
• Standard organization
• Shows care plan and delivery
• Should emphasize charting only essential
information
• Provides an integrated medical record
Negatives of POMR
• Chronology rather than priority
• Possible duplication (assessments and
interventions can apply to more than one
problem)
• Routine care may be undocumented
• Does not work well in settings with high
patient turnover
• Training time for staff to use SOAP, etc.
format
More on SOAP
• S – Subjective
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What the client says (example?)
What the client thinks (example?)
How the client feels (example?)
What the client tells you about his or her illness,
injury, disability, etc. (example?)
– What the client tells you about his/her medical or
treatment history (example?)
– Same information from family members
More on SOAP
• O – Objective
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Everything observed or done by therapist
Results of tests or assessments
Vital signs
Client’s demonstrated abilities or performance
Medical chart information
More on SOAP
• A – Assessment
– Your conclusions based on S and O
• P – Plan
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Immediate treatment
Specific, measurable
Expected outcomes
In POMR, relates to one problem, concern,
complaint
Where does each statement belong?
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Pt states leg hurts
BP 130/85
Pt says he is tired
Pt fell asleep
Within 2 wks, Pt will walk 25 yds unassisted
Pt meets DSM-IV-TR definition of uni polar
depression Diagnostic and Statistical Manual of Mental Disorders
Where does each statement belong?
• HR = 100
• Client’s mother says he is happy
• Client will attend leisure education classes 3x
week
• Within one week, client will be able to define
leisure resources
• Client has limited mobility due to stress fx
More Practice
• You are a recreational therapist and have had
a chance to interview an older man who is in
an assisted living facility. Mr. Jones is a
widower who is 80 years old and, according to
his medical chart, is in reasonably good
health. His height, weight, blood pressure and
heart rate are all average. He complains of
boredom and lack of challenge in the activities
available to him.
Mr. Jones cont’d
• Mr. Jones says that he used to go to bed early
and to get up early because he liked to walk
in the morning with Mrs. Jones but he does
not like to walk alone. When asked, he says
that he does not believe anyone else in the
facility is interested in walking with him, but
he admits that he does not know anyone else
very well. Mr. Jones still goes to bed early but
sometimes he sleeps very late and he has also
gotten in the habit of taking afternoon naps.
Mr. Jones cont’d
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Subjective?
Objective?
Assessment?
Plan?
SOAPIE, SOAPIER
• I – Intervention (implementing the plan)
• E - Evaluation
• R – Revision
• It starts to get more and more complicated…
Other types of documentation or
charting
• Focus – developed in part in response to
SOAP
• Each series (DAR following) refers to a ‘focus’
• A ‘focus’ can be a sign or symptom, a
diagnosis, patient behavior, special need,
change in patient’s condition, significant event
FOCUS
– D –Data – subjective and objective
– A – Action – immediate and future actions
(assessment + plan)
– R – response – patient/client response to care
(evaluation in SOAPIE or SOAPIER notes)
– Example
Focus/DAR
• Flexible
• Process-oriented
• Some of the same problems as with SOAP –
lengthy, duplication, difficult to sort out what
is REALLY important, etc.
CBE – Charting By Exception
• Goals:
– Eliminate lengthy and repetitive notes
– Eliminate poorly organized information (how to
determine what is important?)
– Eliminate possibility of overlooking the really
important things
CBE – Charting By Exception
• Facilities that use CBE will have explicit
guidelines
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Diagnosis based standardized care plans
Patient care guidelines – individualized per patient
Prescribed medical interventions (physician orders)
Incidental orders – one time or infrequent things
• Standards of ordinary care are spelled out (no
need to chart everything)
• Acceptable level of routine care is spelled out
CBE – Charting By Exception
• To simplify – charting/documenting is centered on
things that are wrong, abnormal, out of the ordinary
• Time and space is not taken up to write normal care,
of course, this assumes that normal care is always
done
• May be brief, lack some of the information provided
by other forms
• Development of standards of care is time consuming;
standards must be clearly understood before this
method can be used
Automated Systems
• Vary by organization (+ or – depending on
ease of use of system)
• Immediate retrieval/sharing of information by
all members of treatment team (+)
• May need to share equipment (-)
• Has some built in programming and prompts
(+ for standards and accreditation, things
can’t get left out; - for flexibility, some things
cannot be put in)
Automated Systems
• Advantages probably outweigh disadvantages
• Immediate retrieval/sharing of pt/client information
with any other facility in the world, storage far more
simple than paper records
– Obvious concerns about privacy apply
• Should simplify billing, scheduling, treatment, etc.
• Clients/patients can become more involved in care if
they can access systems from home (outpatient care)