Send the link below via email or IMCopy
Present to your audienceStart remote presentation
- Invited audience members will follow you as you navigate and present
- People invited to a presentation do not need a Prezi account
- This link expires 10 minutes after you close the presentation
- A maximum of 30 users can follow your presentation
- Learn more about this feature in our knowledge base article
Do you really want to delete this prezi?
Neither you, nor the coeditors you shared it with will be able to recover it again.
Make your likes visible on Facebook?
Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.
Transcript of Documentation
Florida International University Documentation Documentation are "written records" on:
actions taken for the patient/client
by the patient/ client
"If it's not in writing, it didn't happen"
(Stumbo & Peterson p. 300) Importance of Documentation What is documentation? Reasons:
Official legal Records
It verifies the "process" that happens with and to clients in order to achieve measurable and predictable outcomes (Stumbo & Peterson p. 300).
Provides a check and balance for TRAM (Therapeutic Recreation Accountability Model) Types of Documentation Client Management:
Regards to individual patient/client outcomes
Examples: assessments, treatment/ program plans,
progress notes, discharge/referral plan
Regards to groups of patients/clients, administrative,
supervisory, or programmatic records
Examples: Comprehensive Program Plan (CPP), Specific
Program Plan (SPP), Policies, Procedures, TR written plan of operations Reasons for Documentation According to Stumbo & Peterson (2009), rationale for documentation are:
Assurance of Quality Services
Facilitation of Communication among staff
Professional Accountability and Self- Regulation
Compliance with Administrative Requirements
Corporation & Multi-facility Agencies
Third- party payers
Provision of Data for Quality Improvement/ Efficacy Research Principles of Quality Documentations Stumbo & Peterson (2009) referred to the 3 C's of good charting:
Clarity Provides update on patient/client treatment plan. Discharge Documentation Elements to include in a discharge note:
Services Received by the Patient/Client
Client's Responses to RT Treatment Plan
Remaining Problems or Concerns
Plan for Postdischarge Progress Notes Terminology Person-First Terminology:
Focuses on the person rather than the disability. Other Elements of Documentation Goals
Condition, Behavior, and Criteria Resources