Guest guest Posted May 16, 1999 Report Share Posted May 16, 1999 D/C information can be incorporated into daily notes in the acute care setting. At our facility, it is a requirement to update goals and state the functional status on a daily basis. If the recommendations for continuum of care changes from evaluation, then that information is included in the daily notes. Our hope is to document smarter and not create more unnecessary paperwork. I can only say that this system works for us and complies with all regulations. Bob Rohack, PT ------------------------------------------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 17, 1999 Report Share Posted May 17, 1999 One other reason for a D/C summary, which may have been noted already, is risk management. As a former defense attorney, I can say that it is difficult to defend any health care negligence/malpractice action where there is no documentation setting forth what condition the patient was in at D/C, what education he was given, etc. I know all this paperwork is time consuming, but you just never know who's going to serve you with papers 6months, a year, 2 years down the road. By that point, personnel/witnesses may have moved on and, with all the patients you see, any one patient probably wouldn't stick out in your memory anyway. All you have to prove what you did is your documentation - and if you didn't document something, it wasn't done. Just my $.02. Laurie Walsh, PT, Esq Daemen College >There are many reasons to do a discharge summary on all patients. Not >the least of which is that it is the Standard of Care of our Profession >(see the appendix of the Guide to Physical Therapist Practice, appendix >2-1. From the JCAHO perspective they may look for both a policy about >discharging patients, and involvement in discharge planning on patients >seen by physical therapy, since there is lots of language in their >standards about both (see section on Care of Patients). Also, the JCAHO >standards require that you adhere to all applicable state and federal >law, regulations etc., including licensure regulations. If you practice >in a state like Massachusetts which codifies our Standard of Practice in >our licensure regulations, then you would be required to do discharge >summaries for no less than 3 reasons! You might want to consider a >policy that describes in detail the extent you do a discharge summary, >and under what conditions. For instance, the policy might say that for >patients who are seen for one visit only, the initial evaluation serves >as the discharge summary of the patient's status and is so indicated on >the form (or note)....as an example, and define other such situations. >How do you handle/document " lost to follow up " ?, as another example of >what your policy might articulate. I think you would be most vulnerable >to a JCAHO survey if you were both silent (e.g. no policy) about how you >managed discharge, and were inconsistent about it in actual practice >too. A policy would allow you to describe how brief, or expansive a > " discharge summary " had to be specific to the unique circumstances of >your facility, but still consistent w/accepted standards of practice, >and applicable state and federal law. > > E. Arslanian, MS, PT >Director of Rehabilition Services >Brigham & Women's Hospital >Boston, MA >larslanian1@... > > >> Discharge Summaries >> >> What policies do acute settings have in place as it relateses to >> discharge summaries. Specifically, do you require a D/C note on >> patients seen briefly (i.e. 2 days) or weekend discharges (MR chart is >> gone when therapists return on Monday). I would appreciate any >> insight >> from what other facilities are doing. (Can you tell JCAHO is coming) >> T >> >> ^^^^^^^^^^^^^^^^ >> Todd Cepica, P.T. >> Director of Physical Medicine and Rehabilitation >> University Medical Center >> Lubbock, Tx 79417 >> Ph: Fax: >> ntc@... >> >> >> >> >> ---------------------------------------------------------------------- >> -- >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 17, 1999 Report Share Posted May 17, 1999 " What policies do acute settings have in place as it relateses to discharge summaries. " In our acute care facility we do not require a PT D/C summary, the physician is responsible for the discharge summary of the patient. W. Sterba, PT ------------------------------------------------------------------------ eGroups.com home: /group/ptmanager - Simplifying group communications Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 17, 1999 Report Share Posted May 17, 1999 We have to do a discharge summary per our practice act. No matter what. >>> Todd Cepica 05/14 8:16 AM >>> What policies do acute settings have in place as it relateses to discharge summaries. Specifically, do you require a D/C note on patients seen briefly (i.e. 2 days) or weekend discharges (MR chart is gone when therapists return on Monday). I would appreciate any insight from what other facilities are doing. (Can you tell JCAHO is coming) T ^^^^^^^^^^^^^^^^ Todd Cepica, P.T. Director of Physical Medicine and Rehabilitation University Medical Center Lubbock, Tx 79417 Ph: Fax: ntc@... ------------------------------------------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 17, 1999 Report Share Posted May 17, 1999 Yes, we do a d/c summary. This is the only place where discharge information appears in a coordinated manner and a final statement of function appears. For the patients that are seen by an assistant, this shows supervision for the state. In theory the note should be on the chart at the time of discharge. It is problematic since a patient can be discharged at any time with out notice. These notes are frequently held out a few days for the original evaluating therapist to review/sign. >>> Warren Sterba 05/17/99 10:37AM >>> " What policies do acute settings have in place as it relateses to discharge summaries. " In our acute care facility we do not require a PT D/C summary, the physician is responsible for the discharge summary of the patient. W. Sterba, PT ------------------------------------------------------------------------ eGroups.com home: /group/ptmanager - Simplifying group communications ------------------------------------------------------------------------ eGroups.com home: /group/ptmanager - Simplifying group communications Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 17, 1999 Report Share Posted May 17, 1999 We do have a discharge summary policy. It basically states that the discharge is just as important as the initial. It should summarize the patient's response to treatment. If the discharge is over the weekend the therapist will need to have that chart pulled and complete the summary within 48 hrs. of discharge. Hope this helps a little. Mandy Volk, PT Mvolk@... Discharge Summaries What policies do acute settings have in place as it relateses to discharge summaries. Specifically, do you require a D/C note on patients seen briefly (i.e. 2 days) or weekend discharges (MR chart is gone when therapists return on Monday). I would appreciate any insight from what other facilities are doing. (Can you tell JCAHO is coming) T ^^^^^^^^^^^^^^^^ Todd Cepica, P.T. Director of Physical Medicine and Rehabilitation University Medical Center Lubbock, Tx 79417 Ph: Fax: ntc@... ------------------------------------------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 17, 1999 Report Share Posted May 17, 1999 There are many reasons to do a discharge summary on all patients. Not the least of which is that it is the Standard of Care of our Profession (see the appendix of the Guide to Physical Therapist Practice, appendix 2-1. From the JCAHO perspective they may look for both a policy about discharging patients, and involvement in discharge planning on patients seen by physical therapy, since there is lots of language in their standards about both (see section on Care of Patients). Also, the JCAHO standards require that you adhere to all applicable state and federal law, regulations etc., including licensure regulations. If you practice in a state like Massachusetts which codifies our Standard of Practice in our licensure regulations, then you would be required to do discharge summaries for no less than 3 reasons! You might want to consider a policy that describes in detail the extent you do a discharge summary, and under what conditions. For instance, the policy might say that for patients who are seen for one visit only, the initial evaluation serves as the discharge summary of the patient's status and is so indicated on the form (or note)....as an example, and define other such situations. How do you handle/document " lost to follow up " ?, as another example of what your policy might articulate. I think you would be most vulnerable to a JCAHO survey if you were both silent (e.g. no policy) about how you managed discharge, and were inconsistent about it in actual practice too. A policy would allow you to describe how brief, or expansive a " discharge summary " had to be specific to the unique circumstances of your facility, but still consistent w/accepted standards of practice, and applicable state and federal law. E. Arslanian, MS, PT Director of Rehabilition Services Brigham & Women's Hospital Boston, MA larslanian1@... > Discharge Summaries > > What policies do acute settings have in place as it relateses to > discharge summaries. Specifically, do you require a D/C note on > patients seen briefly (i.e. 2 days) or weekend discharges (MR chart is > gone when therapists return on Monday). I would appreciate any > insight > from what other facilities are doing. (Can you tell JCAHO is coming) > T > > ^^^^^^^^^^^^^^^^ > Todd Cepica, P.T. > Director of Physical Medicine and Rehabilitation > University Medical Center > Lubbock, Tx 79417 > Ph: Fax: > ntc@... > > > > > ---------------------------------------------------------------------- > -- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 18, 1999 Report Share Posted May 18, 1999 We do require a discharge summary on all patients in our acute care setting. We try to refer back to initial evals or flowsheets for objective information on patients who were seen briefly but require full assessments at time of d/c. > Discharge Summaries > > What policies do acute settings have in place as it relateses to discharge > summaries. Specifically, do you require a D/C note on patients seen > briefly (i.e. 2 days) or weekend discharges (MR chart is gone when > therapists return on Monday). I would appreciate any insight from what > other facilities are doing. (Can you tell JCAHO is coming) > T > > ^^^^^^^^^^^^^^^^ > Todd Cepica, P.T. > Director of Physical Medicine and Rehabilitation > University Medical Center > Lubbock, Tx 79417 > Ph: Fax: > ntc@... > > > > ------------------------------------------------------------------------ > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 18, 1999 Report Share Posted May 18, 1999 Re: Need for D/C Summaries They are a standard for the profession, and they are required in Medicare providers. The fact that these need to be completed, as the evaluation was completed, and that these are documents, not merely procedures begs us to address a predicament in which many of our colleagues find themselves. Many therapists now find that they are expected to find billable units for 100% of their 40 hours per week. Some are at 80% (32 hours billable) or 70% (28 billable hours). The payors do not wish to be billed -- OK , some don't care whether they're billed, because they aren't going to pay for documentation time. The Eval, Prog Notes, and Discharge summary, the team meetings, rounds, inservices, as well as the desirable but not required letters to the doctor all must be accomplished in that non-billable time. It's still work which must be done during business hours. Dick Hillyer, MBA, MSM, PT eGroups.com home: /group/ptmanager www. - Simplifying group communications Quote Link to comment Share on other sites More sharing options...
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