Professionalism in Clinical Documentation

Excellent therapists are no longer defined by clinical skills alone. In today’s evolving healthcare climate, clinicians must be able to reflect the skilled nature of their problem solving abilities, direct care services and measurements of postive patient outcomes with precision.  Therapy documentation may be used to determine if payment criteria are met under medical review.  But keep in mind that your entries may also be scrutinized as part of a legal dispute and analyzed during facility surveys.  The following tips will help you to meet the challenge of maintaining professional standards of documentation:

Professionalism Standards

•  Consistently document objectively (what you saw, heard, smelled, felt.) If you have to document someone else’s observation, identify them as such “Restorative aide reported resident was unable to WB on LLE during transfer today.”
• The medical record is not the place to accuse or record frustrations re: lack of follow through. e.g. “nursing not applying splint as recommended by OT. This puts the facility at risk for survey problems. Instead, train staff to go through the proper channels to address issues (RD/DON) to get the best patient outcomes. We need to work with the facility to problem solve and correct breakdowns in care appropriately.     If subjective comments are made about a care problem, surveyors will expect that measures are taken to resolve that issue and the measures must be documented by the interdisciplinary team. Always maintain a professional “tone” in documentation
• Avoid statements that label a resident. Avoid comments like “confused, combative, difficult, unmotivated” as these terms do not describe what behavior is occurring. If there is reasonable expectation for progress in therapy and you are continuing services, focus on the objective factors that support continuation of services, your skilled interventions to overcome remaining deficits and areas of progress.
• Reflect the skilled nature of your services through mention of evidence based practices utilized for the condition being treated. Describe specific treatment techniques chosen to address a particular clinical complexity. Using formalized tests and scales to show objective measures of deficits compared to normative data and to reflect progress over the rehab course demonstrates sophistication of therapy services beyond the level of non-skilled caregivers.

Source: Nursing & Therapy Documentation in Long Term Care: Skills for Collaboration and Compliance. Kate Brewer, PT, MBA, GCS, RAC-CT and Theresa Lang, RN, BSN, RAC-C, WCC