Re: interdisciplinary documentation

[Guest guest]

,

I cannot speak from personal experience, but a peer here in town had her

notes combined into the nursing bi-fold. What she ended up with were teensy

weensy little areas to write the patient's daily progress in. I believe the

room for evals was also very small (it may have been the same space allotted

to daily notes, I cannot remember). The nurses were adamant that the rehab

disciplines document nursing's way and follow their format.

So my word of caution would be to be sure you are still able to document

what is necessary. As far as reimbursement, you can get written directions

from your Medicare FI about what needs to be there for Medicare

reimbursement. You could also call insurers you deal with to find out what

they require. You may need that outside documentation if things get dicey.

Contact me if you want more info.

Mark Dwyer, MHA, PT

Director of Rehabilitation Services

Bethany Medical Center

Kansas City, Kansas

mdwyer1@...

interdisciplinary documentation

> I need some input. An interdisciplinary group at our facility is

>tackling the task of interdisciplinary documentation. Nursing has been hit

>pretty hard in our last JCAHO survey, while Rehab was commended. Rehab has

>been using SOAP note format and filing notes under PT,OT, or ST tabs in the

>medical chart, with a brief summary in the Physican Progress Note section.

>Nursing has been struggling with a cumbersome Nursing assessment on admit,

>and the Kardex.

> We originally met to discuss the development of an interdisciplinary

>Kardex as a quick snapshot of patient condition/progress with POC, to be

used

>by all disciplines as a quick communication tool across all shifts. Now we

>have segued into " what if " discussion of a multidisciplinary document that

>would contain daily nursing assessment, and charting by exception for all

>other disciplines. So far I can accept and welcome all of this. The hard

>part for me is the discussion coming from Nursing that this theoretical

>document would be the ONLY patient charting.

> Am I being narrow minded when I feel that the Rehab SOAP note is : 1)

>required for reimbursement issues, 2) the continuity between rehab

therapists

>working with the same patient at different times--charting by exception

would

>eliminate much of this? However, it would save a lot of time.

> I am really struggling with wanting to be team-minded, but not

>wanting to throw out the baby with the bath water. Does anyone out there

>have experience with this dilemma, and how did it resolve? Does anyone use

a

>multidisciplinary form that incorporates the ideas set out above--and

willing

>to share?

> Thanks in advance,

> S. Porter, M.A., CCC

>Rehab Services Director

>Northern Virginia Community Hospital

>Arlington, VA

>

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[Guest guest]

; I would also suggest that you reference the " Guidelines for

Physical Therapy Documentation " (APTA) as the standard of our practice

when collaborating on this issue at your facility. This might help

validate what we need to document from the perspective of our

profession.

E. Arslanian, MS, PT

Director of Rehabilitation Services

Brigham & Women's Hospital

Boston, MA

larslanian1@...

> interdisciplinary documentation

>

>

> > I need some input. An interdisciplinary group at our facility is

> >tackling the task of interdisciplinary documentation. Nursing has

> been hit

> >pretty hard in our last JCAHO survey, while Rehab was commended.

> Rehab has

> >been using SOAP note format and filing notes under PT,OT, or ST tabs

> in the

> >medical chart, with a brief summary in the Physican Progress Note

> section.

> >Nursing has been struggling with a cumbersome Nursing assessment on

> admit,

> >and the Kardex.

> > We originally met to discuss the development of an interdisciplinary

> >Kardex as a quick snapshot of patient condition/progress with POC, to

> be

> used

> >by all disciplines as a quick communication tool across all shifts.

> Now we

> >have segued into " what if " discussion of a multidisciplinary document

> that

> >would contain daily nursing assessment, and charting by exception for

> all

> >other disciplines. So far I can accept and welcome all of this. The

> hard

> >part for me is the discussion coming from Nursing that this

> theoretical

> >document would be the ONLY patient charting.

> > Am I being narrow minded when I feel that the Rehab SOAP note is :

> 1)

> >required for reimbursement issues, 2) the continuity between rehab

> therapists

> >working with the same patient at different times--charting by

> exception

> would

> >eliminate much of this? However, it would save a lot of time.

> > I am really struggling with wanting to be team-minded, but not

> >wanting to throw out the baby with the bath water. Does anyone out

> there

> >have experience with this dilemma, and how did it resolve? Does

> anyone use

> a

> >multidisciplinary form that incorporates the ideas set out above--and

> willing

> >to share?

> > Thanks in advance,

> > S. Porter, M.A., CCC

> >Rehab Services Director

> >Northern Virginia Community Hospital

> >Arlington, VA

> >

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> >eGroups.com home: /group/ptmanager

> > - Simplifying group communications

> >

> >

> >

> >

> >

>

>

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> eGroups.com home: /group/ptmanager

> - Simplifying group communications

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