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Documentation

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by

Melina Rojas

on 26 April 2013

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Transcript of Documentation

Melina M. Rojas
Florida International University Documentation Documentation are "written records" on:
actions taken for the patient/client
with patient/client
by the patient/ client
Main Idea:
"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
Program Management:
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
Agency Administration
Corporation & Multi-facility Agencies
Accreditation Agency
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:
Consistency
Conciseness
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
Objectives
Condition, Behavior, and Criteria Resources
Full transcript