Documentation in Rehabilitation

It goes something like this… “Patient seen for initial physical therapy evaluation on Aug 7th 2008. Patient is a 65-year old male, who sustained a CVA on June 26th 2008. Patient was accompanied to the ER when complaints of…”. Documentation, commonly referred to as “notes” is often the bane of the rehabilitation professionals work day. It is common to hear therapists and nurses and physicians mention how much they enjoy interacting with their patients and treating them; but they often have less positive things to say about the documentation process.

In the USA, there has been growing emphasis on documentation and maintaining good health records in the field of healthcare over the past few years. As a rehabilitation professional, I used to find summarizing the activities of a one-hour session into a paragraph of words somewhat challenging. But over the years, one tends to accept medical notes as part of one’s work, gradually getting more efficient at it. Documentation is primarily viewed as a means to communicate episodes of care to third party payers for reimbursement purposes. However, detailed documentation and well-organized records also serve to benefit the healthcare professional and the consumer. Some of the benefits of good quality documentation are:

• Maintaining records so that administrative operations may be evaluated based on the recommendations of accrediting and certifying organizations.
• Maintaining privacy and security of personal healthcare records.
• Maintaining records to keep up with the expectations of the educated consumer.
• Legal record of all communication between professional and consumer in case of disputes.

In the field of therapy and rehabilitation, the typical evaluation form has a section for goal setting. Personally, I think this is invaluable, as it gives the professional a chance to ask patients and their families what their expectations from therapy are, thereby including them in the process from the beginning. This is the foundation of the Interdisciplinary model of healthcare delivery, which places the patient and family at the center of the planning process. When goals are set early on, the rehabilitation plan is better outlined and specific to the patients’ needs. Studies have indicated that efficient goal planning and documentation improve patient compliance and participation in the program. Studies also suggest that concise and systematic goal planning has a positive effect on patient outcome.

To increase efficiency and ease of storage, hospitals and clinics are moving form the traditional pen and paper documentation toward electronic medical records (EMR). The technology boom has certainly affected healthcare; now documentation may be done on word processing software, over the Internet, or telephonically via dictation systems.

“Working from home” — a concept alien in rehabilitation — is now becoming a possibility; the EMR gives therapists the choice of completing notes at home.

Studies suggested that EMR improved reporting capabilities, and provided a standardized system to analyze and measure therapy outcomes. Studies also showed that EMR enabled individualized treatment planning for clients. Other benefits of EMR included improved efficiency of patient admission processes, decreased length of rehabilitation stay, improved communication within the team, and reduced duplication of information. Another advantage of the EMR is maintaining continuum of care, as the records are available to the entire treatment team for reference and for planning treatment sessions.

Maintaining current and accurate medical records is the responsibility of every healthcare professional. There are more advantages than disadvantages to this and timeliness of documentation benefits the consumer, the providers and companies that bear healthcare costs.