RE: summary lists for hospital based outpatient rehab

[Guest guest]

Eileen:

The patient summary list is form that lists a summary of diagnosis, surgical

interventions, medications and drug allergies. It needs to be filled out ASAP

and no later than 3 visits. To comply with this, we fill it out upon evaluation.

They will not accept your evaluation that lists all this. The requirement is to

ensure that in case of emergency, there is a summary of the medical history and

the current condition you are treating the patient and also provide a structured

process so you can update any new problems or conditions. Feel free to call me

and I can email you our form that works for this and had passed well with JC

survey.

Agnes V. Papa, PT

Director of Rehabilitation

Bert Fish Medical Center

fax

This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

________________________________

From: PTManager [mailto:PTManager ] On Behalf Of

Eileen Casey

Sent: Tuesday, April 12, 2011 2:52 PM

To: PTManager

Subject: summary lists for hospital based outpatient rehab

Good Afternoon,

On a recent JCAHO survey we were cited for not having a " summary list "

for each outpatient. Our initial evaluation form has documented PMH/PSH,

medications, allergies that is completed on the first visit however our

surveyor did not agree that this is a " summary list " .

As we are a small rural hospital we do not have a full EMR so a summary

list that is " readily available to all practitioners and updated

whenever there is a change in diagnosis, medications or allergies and

whenever a procedure is performed " per JCAHO is not in place.

Has anyone else dealt with this situation? Any suggestions?

Eileen Casey, PT

Director of Rehab Services

Brattleboro Memorial Hospital

17 Belmont Ave

Brattleboro, VT 05301

ecasey@...<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@...<mailto:ecasey%40bmhvt.org>>

__________________________________________________________

The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

__________________________________________________________

[Guest guest]

Eileen:

The patient summary list is form that lists a summary of diagnosis, surgical

interventions, medications and drug allergies. It needs to be filled out ASAP

and no later than 3 visits. To comply with this, we fill it out upon evaluation.

They will not accept your evaluation that lists all this. The requirement is to

ensure that in case of emergency, there is a summary of the medical history and

the current condition you are treating the patient and also provide a structured

process so you can update any new problems or conditions. Feel free to call me

and I can email you our form that works for this and had passed well with JC

survey.

Agnes V. Papa, PT

Director of Rehabilitation

Bert Fish Medical Center

fax

This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

________________________________

From: PTManager [mailto:PTManager ] On Behalf Of

Eileen Casey

Sent: Tuesday, April 12, 2011 2:52 PM

To: PTManager

Subject: summary lists for hospital based outpatient rehab

Good Afternoon,

On a recent JCAHO survey we were cited for not having a " summary list "

for each outpatient. Our initial evaluation form has documented PMH/PSH,

medications, allergies that is completed on the first visit however our

surveyor did not agree that this is a " summary list " .

As we are a small rural hospital we do not have a full EMR so a summary

list that is " readily available to all practitioners and updated

whenever there is a change in diagnosis, medications or allergies and

whenever a procedure is performed " per JCAHO is not in place.

Has anyone else dealt with this situation? Any suggestions?

Eileen Casey, PT

Director of Rehab Services

Brattleboro Memorial Hospital

17 Belmont Ave

Brattleboro, VT 05301

ecasey@...<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@...<mailto:ecasey%40bmhvt.org>>

__________________________________________________________

The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

__________________________________________________________

[Guest guest]

Eileen:

The patient summary list is form that lists a summary of diagnosis, surgical

interventions, medications and drug allergies. It needs to be filled out ASAP

and no later than 3 visits. To comply with this, we fill it out upon evaluation.

They will not accept your evaluation that lists all this. The requirement is to

ensure that in case of emergency, there is a summary of the medical history and

the current condition you are treating the patient and also provide a structured

process so you can update any new problems or conditions. Feel free to call me

and I can email you our form that works for this and had passed well with JC

survey.

Agnes V. Papa, PT

Director of Rehabilitation

Bert Fish Medical Center

fax

This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

________________________________

From: PTManager [mailto:PTManager ] On Behalf Of

Eileen Casey

Sent: Tuesday, April 12, 2011 2:52 PM

To: PTManager

Subject: summary lists for hospital based outpatient rehab

Good Afternoon,

On a recent JCAHO survey we were cited for not having a " summary list "

for each outpatient. Our initial evaluation form has documented PMH/PSH,

medications, allergies that is completed on the first visit however our

surveyor did not agree that this is a " summary list " .

As we are a small rural hospital we do not have a full EMR so a summary

list that is " readily available to all practitioners and updated

whenever there is a change in diagnosis, medications or allergies and

whenever a procedure is performed " per JCAHO is not in place.

Has anyone else dealt with this situation? Any suggestions?

Eileen Casey, PT

Director of Rehab Services

Brattleboro Memorial Hospital

17 Belmont Ave

Brattleboro, VT 05301

ecasey@...<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@...<mailto:ecasey%40bmhvt.org>>

__________________________________________________________

The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

__________________________________________________________

[Guest guest]

Eileen,

We have every patient fill out and sign a patient intake questionnaire that

includes all the information you mentioned. Each patient is asked to arrive

15-20 minutes early for this and other necessary paperwork.

It saves the therapist a lot of time and should suffice for JCAHO's

requirements. In essence, it is a " summary list " from the patient's own hand.

I don't see how JCAHO could find fault with a patient's own account of this

information.

Jon Mark Pleasant, PT

Methodist Medical Center

>

>

>

> Good Afternoon,

>

> On a recent JCAHO survey we were cited for not having a " summary list "

> for each outpatient. Our initial evaluation form has documented PMH/PSH,

> medications, allergies that is completed on the first visit however our

> surveyor did not agree that this is a " summary list " .

>

> As we are a small rural hospital we do not have a full EMR so a summary

> list that is " readily available to all practitioners and updated

> whenever there is a change in diagnosis, medications or allergies and

> whenever a procedure is performed " per JCAHO is not in place.

>

> Has anyone else dealt with this situation? Any suggestions?

>

>

>

> Eileen Casey, PT

>

> Director of Rehab Services

>

> Brattleboro Memorial Hospital

>

> 17 Belmont Ave

>

> Brattleboro, VT 05301

>

>

>

> ecasey@...

>

>

>

>

>

>

> _______________________________________________________________

>

> The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

> _______________________________________________________________

>

>

>

[Guest guest]

Hello Group,

Thanks for the information. I wanted to ask you regarding the summary list. In

the event that the patient is unable to fill out the summary list themselves....

Is it true that it is a JC requirement that it has to be the evaluating

therapist who helps patient fill out this summary list ?

Is it also true that JC does not allow a system where registration staff helps

patient fill out the summary list and then evaluating therapist would review and

sign it ?

Thanks

Nat,

MI

I

>

> Eileen:

>

> The patient summary list is form that lists a summary of diagnosis, surgical

interventions, medications and drug allergies. It needs to be filled out ASAP

and no later than 3 visits. To comply with this, we fill it out upon evaluation.

They will not accept your evaluation that lists all this. The requirement is to

ensure that in case of emergency, there is a summary of the medical history and

the current condition you are treating the patient and also provide a structured

process so you can update any new problems or conditions. Feel free to call me

and I can email you our form that works for this and had passed well with JC

survey.

>

> Agnes V. Papa, PT

> Director of Rehabilitation

> Bert Fish Medical Center

> fax

> This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

>

> ________________________________

> From: PTManager [mailto:PTManager ] On Behalf

Of Eileen Casey

> Sent: Tuesday, April 12, 2011 2:52 PM

> To: PTManager

> Subject: summary lists for hospital based outpatient rehab

>

>

>

>

> Good Afternoon,

>

> On a recent JCAHO survey we were cited for not having a " summary list "

> for each outpatient. Our initial evaluation form has documented PMH/PSH,

> medications, allergies that is completed on the first visit however our

> surveyor did not agree that this is a " summary list " .

>

> As we are a small rural hospital we do not have a full EMR so a summary

> list that is " readily available to all practitioners and updated

> whenever there is a change in diagnosis, medications or allergies and

> whenever a procedure is performed " per JCAHO is not in place.

>

> Has anyone else dealt with this situation? Any suggestions?

>

> Eileen Casey, PT

>

> Director of Rehab Services

>

> Brattleboro Memorial Hospital

>

> 17 Belmont Ave

>

> Brattleboro, VT 05301

>

>

>

> ecasey@...<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@...<mailto:ecasey%40bmhvt.org>>

>

> __________________________________________________________

>

> The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

> __________________________________________________________

>

>

[Guest guest]

Hello Group,

Thanks for the information. I wanted to ask you regarding the summary list. In

the event that the patient is unable to fill out the summary list themselves....

Is it true that it is a JC requirement that it has to be the evaluating

therapist who helps patient fill out this summary list ?

Is it also true that JC does not allow a system where registration staff helps

patient fill out the summary list and then evaluating therapist would review and

sign it ?

Thanks

Nat,

MI

I

>

> Eileen:

>

> The patient summary list is form that lists a summary of diagnosis, surgical

interventions, medications and drug allergies. It needs to be filled out ASAP

and no later than 3 visits. To comply with this, we fill it out upon evaluation.

They will not accept your evaluation that lists all this. The requirement is to

ensure that in case of emergency, there is a summary of the medical history and

the current condition you are treating the patient and also provide a structured

process so you can update any new problems or conditions. Feel free to call me

and I can email you our form that works for this and had passed well with JC

survey.

>

> Agnes V. Papa, PT

> Director of Rehabilitation

> Bert Fish Medical Center

> fax

> This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

>

> ________________________________

> From: PTManager [mailto:PTManager ] On Behalf

Of Eileen Casey

> Sent: Tuesday, April 12, 2011 2:52 PM

> To: PTManager

> Subject: summary lists for hospital based outpatient rehab

>

>

>

>

> Good Afternoon,

>

> On a recent JCAHO survey we were cited for not having a " summary list "

> for each outpatient. Our initial evaluation form has documented PMH/PSH,

> medications, allergies that is completed on the first visit however our

> surveyor did not agree that this is a " summary list " .

>

> As we are a small rural hospital we do not have a full EMR so a summary

> list that is " readily available to all practitioners and updated

> whenever there is a change in diagnosis, medications or allergies and

> whenever a procedure is performed " per JCAHO is not in place.

>

> Has anyone else dealt with this situation? Any suggestions?

>

> Eileen Casey, PT

>

> Director of Rehab Services

>

> Brattleboro Memorial Hospital

>

> 17 Belmont Ave

>

> Brattleboro, VT 05301

>

>

>

> ecasey@...<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@...<mailto:ecasey%40bmhvt.org>>

>

> __________________________________________________________

>

> The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

> __________________________________________________________

>

>

[Guest guest]

Hello Group,

Thanks for the information. I wanted to ask you regarding the summary list. In

the event that the patient is unable to fill out the summary list themselves....

Is it true that it is a JC requirement that it has to be the evaluating

therapist who helps patient fill out this summary list ?

Is it also true that JC does not allow a system where registration staff helps

patient fill out the summary list and then evaluating therapist would review and

sign it ?

Thanks

Nat,

MI

I

>

> Eileen:

>

> The patient summary list is form that lists a summary of diagnosis, surgical

interventions, medications and drug allergies. It needs to be filled out ASAP

and no later than 3 visits. To comply with this, we fill it out upon evaluation.

They will not accept your evaluation that lists all this. The requirement is to

ensure that in case of emergency, there is a summary of the medical history and

the current condition you are treating the patient and also provide a structured

process so you can update any new problems or conditions. Feel free to call me

and I can email you our form that works for this and had passed well with JC

survey.

>

> Agnes V. Papa, PT

> Director of Rehabilitation

> Bert Fish Medical Center

> fax

> This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

>

> ________________________________

> From: PTManager [mailto:PTManager ] On Behalf

Of Eileen Casey

> Sent: Tuesday, April 12, 2011 2:52 PM

> To: PTManager

> Subject: summary lists for hospital based outpatient rehab

>

>

>

>

> Good Afternoon,

>

> On a recent JCAHO survey we were cited for not having a " summary list "

> for each outpatient. Our initial evaluation form has documented PMH/PSH,

> medications, allergies that is completed on the first visit however our

> surveyor did not agree that this is a " summary list " .

>

> As we are a small rural hospital we do not have a full EMR so a summary

> list that is " readily available to all practitioners and updated

> whenever there is a change in diagnosis, medications or allergies and

> whenever a procedure is performed " per JCAHO is not in place.

>

> Has anyone else dealt with this situation? Any suggestions?

>

> Eileen Casey, PT

>

> Director of Rehab Services

>

> Brattleboro Memorial Hospital

>

> 17 Belmont Ave

>

> Brattleboro, VT 05301

>

>

>

> ecasey@...<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@...<mailto:ecasey%40bmhvt.org>>

>

> __________________________________________________________

>

> The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

> __________________________________________________________

>

>

[Guest guest]

Nat:

The patient summary list needs to be filled out by the therapist to confirm all

the diagnosis, medications and surgical information. If there are more than one

discipline involved, there should be a process in your department that if one

therapist acknowledges a new diagnosis, they should flag the other therapist.

Hence, communication among the caregivers is ensured. If you allow the

registration staff to fill this out, you wont have the process of confirming and

acknowledging the information by a licensed practitioner. Hope this helps.

Agnes V. Papa, PT

Director of Rehabilitation

Bert Fish Medical Center

fax

This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

________________________________

From: PTManager [mailto:PTManager ] On Behalf Of

nits_physio

Sent: Tuesday, April 12, 2011 8:39 PM

To: PTManager

Subject: Re: summary lists for hospital based outpatient rehab

Hello Group,

Thanks for the information. I wanted to ask you regarding the summary list. In

the event that the patient is unable to fill out the summary list themselves....

Is it true that it is a JC requirement that it has to be the evaluating

therapist who helps patient fill out this summary list ?

Is it also true that JC does not allow a system where registration staff helps

patient fill out the summary list and then evaluating therapist would review and

sign it ?

Thanks

Nat,

MI

I

>

> Eileen:

>

> The patient summary list is form that lists a summary of diagnosis, surgical

interventions, medications and drug allergies. It needs to be filled out ASAP

and no later than 3 visits. To comply with this, we fill it out upon evaluation.

They will not accept your evaluation that lists all this. The requirement is to

ensure that in case of emergency, there is a summary of the medical history and

the current condition you are treating the patient and also provide a structured

process so you can update any new problems or conditions. Feel free to call me

and I can email you our form that works for this and had passed well with JC

survey.

>

> Agnes V. Papa, PT

> Director of Rehabilitation

> Bert Fish Medical Center

> fax

> This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

>

> ________________________________

> From: PTManager <mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On Behalf

Of Eileen Casey

> Sent: Tuesday, April 12, 2011 2:52 PM

> To: PTManager <mailto:PTManager%40yahoogroups.com>

> Subject: summary lists for hospital based outpatient rehab

>

>

>

>

> Good Afternoon,

>

> On a recent JCAHO survey we were cited for not having a " summary list "

> for each outpatient. Our initial evaluation form has documented PMH/PSH,

> medications, allergies that is completed on the first visit however our

> surveyor did not agree that this is a " summary list " .

>

> As we are a small rural hospital we do not have a full EMR so a summary

> list that is " readily available to all practitioners and updated

> whenever there is a change in diagnosis, medications or allergies and

> whenever a procedure is performed " per JCAHO is not in place.

>

> Has anyone else dealt with this situation? Any suggestions?

>

> Eileen Casey, PT

>

> Director of Rehab Services

>

> Brattleboro Memorial Hospital

>

> 17 Belmont Ave

>

> Brattleboro, VT 05301

>

>

>

> ecasey@...<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@...<mailto:ecasey%40bmhvt.org>>

>

> __________________________________________________________

>

> The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

> __________________________________________________________

>

>

[Guest guest]

Nat:

The patient summary list needs to be filled out by the therapist to confirm all

the diagnosis, medications and surgical information. If there are more than one

discipline involved, there should be a process in your department that if one

therapist acknowledges a new diagnosis, they should flag the other therapist.

Hence, communication among the caregivers is ensured. If you allow the

registration staff to fill this out, you wont have the process of confirming and

acknowledging the information by a licensed practitioner. Hope this helps.

Agnes V. Papa, PT

Director of Rehabilitation

Bert Fish Medical Center

fax

This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

________________________________

From: PTManager [mailto:PTManager ] On Behalf Of

nits_physio

Sent: Tuesday, April 12, 2011 8:39 PM

To: PTManager

Subject: Re: summary lists for hospital based outpatient rehab

Hello Group,

Thanks for the information. I wanted to ask you regarding the summary list. In

the event that the patient is unable to fill out the summary list themselves....

Is it true that it is a JC requirement that it has to be the evaluating

therapist who helps patient fill out this summary list ?

Is it also true that JC does not allow a system where registration staff helps

patient fill out the summary list and then evaluating therapist would review and

sign it ?

Thanks

Nat,

MI

I

>

> Eileen:

>

> The patient summary list is form that lists a summary of diagnosis, surgical

interventions, medications and drug allergies. It needs to be filled out ASAP

and no later than 3 visits. To comply with this, we fill it out upon evaluation.

They will not accept your evaluation that lists all this. The requirement is to

ensure that in case of emergency, there is a summary of the medical history and

the current condition you are treating the patient and also provide a structured

process so you can update any new problems or conditions. Feel free to call me

and I can email you our form that works for this and had passed well with JC

survey.

>

> Agnes V. Papa, PT

> Director of Rehabilitation

> Bert Fish Medical Center

> fax

> This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

>

> ________________________________

> From: PTManager <mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On Behalf

Of Eileen Casey

> Sent: Tuesday, April 12, 2011 2:52 PM

> To: PTManager <mailto:PTManager%40yahoogroups.com>

> Subject: summary lists for hospital based outpatient rehab

>

>

>

>

> Good Afternoon,

>

> On a recent JCAHO survey we were cited for not having a " summary list "

> for each outpatient. Our initial evaluation form has documented PMH/PSH,

> medications, allergies that is completed on the first visit however our

> surveyor did not agree that this is a " summary list " .

>

> As we are a small rural hospital we do not have a full EMR so a summary

> list that is " readily available to all practitioners and updated

> whenever there is a change in diagnosis, medications or allergies and

> whenever a procedure is performed " per JCAHO is not in place.

>

> Has anyone else dealt with this situation? Any suggestions?

>

> Eileen Casey, PT

>

> Director of Rehab Services

>

> Brattleboro Memorial Hospital

>

> 17 Belmont Ave

>

> Brattleboro, VT 05301

>

>

>

> ecasey@...<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@...<mailto:ecasey%40bmhvt.org>>

>

> __________________________________________________________

>

> The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

> __________________________________________________________

>

>

[Guest guest]

Nat:

The patient summary list needs to be filled out by the therapist to confirm all

the diagnosis, medications and surgical information. If there are more than one

discipline involved, there should be a process in your department that if one

therapist acknowledges a new diagnosis, they should flag the other therapist.

Hence, communication among the caregivers is ensured. If you allow the

registration staff to fill this out, you wont have the process of confirming and

acknowledging the information by a licensed practitioner. Hope this helps.

Agnes V. Papa, PT

Director of Rehabilitation

Bert Fish Medical Center

fax

This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

________________________________

From: PTManager [mailto:PTManager ] On Behalf Of

nits_physio

Sent: Tuesday, April 12, 2011 8:39 PM

To: PTManager

Subject: Re: summary lists for hospital based outpatient rehab

Hello Group,

Thanks for the information. I wanted to ask you regarding the summary list. In

the event that the patient is unable to fill out the summary list themselves....

Is it true that it is a JC requirement that it has to be the evaluating

therapist who helps patient fill out this summary list ?

Is it also true that JC does not allow a system where registration staff helps

patient fill out the summary list and then evaluating therapist would review and

sign it ?

Thanks

Nat,

MI

I

>

> Eileen:

>

> The patient summary list is form that lists a summary of diagnosis, surgical

interventions, medications and drug allergies. It needs to be filled out ASAP

and no later than 3 visits. To comply with this, we fill it out upon evaluation.

They will not accept your evaluation that lists all this. The requirement is to

ensure that in case of emergency, there is a summary of the medical history and

the current condition you are treating the patient and also provide a structured

process so you can update any new problems or conditions. Feel free to call me

and I can email you our form that works for this and had passed well with JC

survey.

>

> Agnes V. Papa, PT

> Director of Rehabilitation

> Bert Fish Medical Center

> fax

> This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

>

> ________________________________

> From: PTManager <mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On Behalf

Of Eileen Casey

> Sent: Tuesday, April 12, 2011 2:52 PM

> To: PTManager <mailto:PTManager%40yahoogroups.com>

> Subject: summary lists for hospital based outpatient rehab

>

>

>

>

> Good Afternoon,

>

> On a recent JCAHO survey we were cited for not having a " summary list "

> for each outpatient. Our initial evaluation form has documented PMH/PSH,

> medications, allergies that is completed on the first visit however our

> surveyor did not agree that this is a " summary list " .

>

> As we are a small rural hospital we do not have a full EMR so a summary

> list that is " readily available to all practitioners and updated

> whenever there is a change in diagnosis, medications or allergies and

> whenever a procedure is performed " per JCAHO is not in place.

>

> Has anyone else dealt with this situation? Any suggestions?

>

> Eileen Casey, PT

>

> Director of Rehab Services

>

> Brattleboro Memorial Hospital

>

> 17 Belmont Ave

>

> Brattleboro, VT 05301

>

>

>

> ecasey@...<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@...<mailto:ecasey%40bmhvt.org>>

>

> __________________________________________________________

>

> The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

> __________________________________________________________

>

>

[Guest guest]

Agnes,

Is this your professional opinion or do you have a written reference you could

provide?

With the exception of previous EMR records or forwarded records from the

patient's doctor, patients and/or patient family members are the original (AND

MOST RELIABLE) source for surgical history, medical history, medication list,

reason for current visit, etc.

If a patient or reliable family member cannot provide an accurate written

account of this information on their own, how would a therapist's written

account be more reliable?

It's hard for me to imagine a JCAHO surveyor discounting or discrediting a

summary list provided directly by a patient they have never met.

These are just my thoughts. If there is information to the contrary, I would

like to see a concrete written reference.

Jon Mark Pleasant, PT

Methodist Medical Center

> >

> > Eileen:

> >

> > The patient summary list is form that lists a summary of diagnosis, surgical

interventions, medications and drug allergies. It needs to be filled out ASAP

and no later than 3 visits. To comply with this, we fill it out upon evaluation.

They will not accept your evaluation that lists all this. The requirement is to

ensure that in case of emergency, there is a summary of the medical history and

the current condition you are treating the patient and also provide a structured

process so you can update any new problems or conditions. Feel free to call me

and I can email you our form that works for this and had passed well with JC

survey.

> >

> > Agnes V. Papa, PT

> > Director of Rehabilitation

> > Bert Fish Medical Center

> > fax

> > This e-mail or the documents accompanying this e-mail contain information

that may be confidential and/or privileged. It may also be prohibited from

disclosure under applicable law. The opinions expressed are those of the sender

and do not necessarily represent the policy or positions of Bert Fish Medical

Center. The information is intended to be for the use of the individual or

entity named on this transmission. If you are not the intended recipient, be

aware that any disclosure, copying, distribution or use of the contents of this

information is without authorization and is prohibited. If you have received

this e-mail in error, please notify us immediately so that we can take action to

correct the problem.

> >

> > ________________________________

> > From: PTManager <mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On Behalf

Of Eileen Casey

> > Sent: Tuesday, April 12, 2011 2:52 PM

> > To: PTManager <mailto:PTManager%40yahoogroups.com>

> > Subject: summary lists for hospital based outpatient rehab

> >

> >

> >

> >

> > Good Afternoon,

> >

> > On a recent JCAHO survey we were cited for not having a " summary list "

> > for each outpatient. Our initial evaluation form has documented PMH/PSH,

> > medications, allergies that is completed on the first visit however our

> > surveyor did not agree that this is a " summary list " .

> >

> > As we are a small rural hospital we do not have a full EMR so a summary

> > list that is " readily available to all practitioners and updated

> > whenever there is a change in diagnosis, medications or allergies and

> > whenever a procedure is performed " per JCAHO is not in place.

> >

> > Has anyone else dealt with this situation? Any suggestions?

> >

> > Eileen Casey, PT

> >

> > Director of Rehab Services

> >

> > Brattleboro Memorial Hospital

> >

> > 17 Belmont Ave

> >

> > Brattleboro, VT 05301

> >

> >

> >

> > ecasey@<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@<mailto:ecasey%40bmhvt.org>>

> >

> > __________________________________________________________

> >

> > The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

> > __________________________________________________________

> >

> >

[Guest guest]

Jon:

The family fills out the surgical history, medical history, medication list (on

a separate form/ patient questionnaire that the patient fills up upon

registration) and then the therapist puts the information in the patient

summary list after the evaluation and initials and dates each entry. Yes, the

patient is of course the reliable source. And yes, if you have EMR, you can add

the other history in that sheet. Our evaluation has all these in the evaluation

and unfortunately we have to repeat everything on the patient summary list.

Based from JC survey experience. Hope this helps you

Agnes V. Papa, PT

Director of Rehabilitation

Bert Fish Medical Center

fax

This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

________________________________

From: PTManager [mailto:PTManager ] On Behalf Of

jonmarkpleasant

Sent: Wednesday, April 13, 2011 2:37 PM

To: PTManager

Subject: Re: summary lists for hospital based outpatient rehab

Agnes,

Is this your professional opinion or do you have a written reference you could

provide?

With the exception of previous EMR records or forwarded records from the

patient's doctor, patients and/or patient family members are the original (AND

MOST RELIABLE) source for surgical history, medical history, medication list,

reason for current visit, etc.

If a patient or reliable family member cannot provide an accurate written

account of this information on their own, how would a therapist's written

account be more reliable?

It's hard for me to imagine a JCAHO surveyor discounting or discrediting a

summary list provided directly by a patient they have never met.

These are just my thoughts. If there is information to the contrary, I would

like to see a concrete written reference.

Jon Mark Pleasant, PT

Methodist Medical Center

> >

> > Eileen:

> >

> > The patient summary list is form that lists a summary of diagnosis, surgical

interventions, medications and drug allergies. It needs to be filled out ASAP

and no later than 3 visits. To comply with this, we fill it out upon evaluation.

They will not accept your evaluation that lists all this. The requirement is to

ensure that in case of emergency, there is a summary of the medical history and

the current condition you are treating the patient and also provide a structured

process so you can update any new problems or conditions. Feel free to call me

and I can email you our form that works for this and had passed well with JC

survey.

> >

> > Agnes V. Papa, PT

> > Director of Rehabilitation

> > Bert Fish Medical Center

> > fax

> > This e-mail or the documents accompanying this e-mail contain information

that may be confidential and/or privileged. It may also be prohibited from

disclosure under applicable law. The opinions expressed are those of the sender

and do not necessarily represent the policy or positions of Bert Fish Medical

Center. The information is intended to be for the use of the individual or

entity named on this transmission. If you are not the intended recipient, be

aware that any disclosure, copying, distribution or use of the contents of this

information is without authorization and is prohibited. If you have received

this e-mail in error, please notify us immediately so that we can take action to

correct the problem.

> >

> > ________________________________

> > From:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTM\

anager%40yahoogroups.com>] On Behalf Of Eileen Casey

> > Sent: Tuesday, April 12, 2011 2:52 PM

> > To:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com>

> > Subject: summary lists for hospital based outpatient rehab

> >

> >

> >

> >

> > Good Afternoon,

> >

> > On a recent JCAHO survey we were cited for not having a " summary list "

> > for each outpatient. Our initial evaluation form has documented PMH/PSH,

> > medications, allergies that is completed on the first visit however our

> > surveyor did not agree that this is a " summary list " .

> >

> > As we are a small rural hospital we do not have a full EMR so a summary

> > list that is " readily available to all practitioners and updated

> > whenever there is a change in diagnosis, medications or allergies and

> > whenever a procedure is performed " per JCAHO is not in place.

> >

> > Has anyone else dealt with this situation? Any suggestions?

> >

> > Eileen Casey, PT

> >

> > Director of Rehab Services

> >

> > Brattleboro Memorial Hospital

> >

> > 17 Belmont Ave

> >

> > Brattleboro, VT 05301

> >

> >

> >

> > ecasey@<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@<mailto:ecasey%40bmhvt.org>>

> >

> > __________________________________________________________

> >

> > The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

> > __________________________________________________________

> >

> >

[Guest guest]

We use a universal " intake form " in our outpatient settings - that

includes the info reqd and also reason for visit etc. It requires

therapist sign off to show it has been reviewed - we also put the med

reconciliation piece on it - if we are potentially doing ionto/ phono.

We use this form also to screen the potential for a lingering Home

Health situation where we need to clear that for payment prior to

initiating OP care. We are currently asking our outpatient therapists

(they are on paper) to enter allergies into our EHR but this is really a

challenge to enforce when they are doing so many other " check points "

The theory being we could be the first point of contact - and if we

identify an allergy - or retrieve the first comprehensive list of meds -

that we should share them with the EHR so they would be available should

the patient end up in the ER. The patient completes the Intake Form

at registration.

Laurie

Sr. Director

________________________________

From: PTManager [mailto:PTManager ] On

Behalf Of Eileen Casey

Sent: Tuesday, April 12, 2011 2:52 PM

To: PTManager

Subject: summary lists for hospital based outpatient rehab

Good Afternoon,

On a recent JCAHO survey we were cited for not having a " summary list "

for each outpatient. Our initial evaluation form has documented PMH/PSH,

medications, allergies that is completed on the first visit however our

surveyor did not agree that this is a " summary list " .

As we are a small rural hospital we do not have a full EMR so a summary

list that is " readily available to all practitioners and updated

whenever there is a change in diagnosis, medications or allergies and

whenever a procedure is performed " per JCAHO is not in place.

Has anyone else dealt with this situation? Any suggestions?

Eileen Casey, PT

Director of Rehab Services

Brattleboro Memorial Hospital

17 Belmont Ave

Brattleboro, VT 05301

ecasey@... <mailto:ecasey%40bmhvt.org> <mailto:ecasey@...

<mailto:ecasey%40bmhvt.org> >

__________________________________________________________

The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the

individual or entity to whom it is addressed and may be subject to legal

privilege. If you have received this e-mail in error you should notify

the sender immediately by reply e-mail, delete the message from your

system and notify your system manager. Please do not copy it for any

purpose, or disclose its contents to any other person. The views or

opinions presented in this e-mail are solely those of the author and do

not necessarily represent those of the company. The recipient should

check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or

indirectly, by any virus transmitted in this email.

__________________________________________________________

[Guest guest]

Agnes,

I'm sure you would agree that rewriting the patient summary information in three

different locations is inefficient and does nothing to improve patient care.

It is my opinion that JCAHO creates pet projects such as this to make it easier

on themselves during their three day survey while not considering the increase

burden that is put on clinicians the other 1092 days (not including leap year).

At some point in the near future when we all will be utilizing EMRs, the patient

summary list will probably be accessed by selecting an appropriately labeled

tab. In other words, the JCAHO surveyor will have to search for it.

With this future EMR search in mind, I would like to suggest we apply this

search method to our present paper charts.

On the front page of your outpatient paper chart, you can simply have a " Search

Index " that directs the surveyor to the appropriate tab (ex. Assessment Tab)

where the patient summary list can be found. The patient summary information

(written by the patient/patient family member) could be conveniently attached to

the therapist's initial evaluation. This way, there is no need for the

therapist to rewrite this information on the evaluation AND on another patient

summary form. The therapist can add information to it in the event the

patient's situation changes.

In effect, you are conveniently directing the JCAHO surveyor to the information

they seek via your front page Search Index. The therapist and the JCAHO

surveyor are performing an old school search similar to how they will search

when we are all on EMRs in the near future.

The real time savings for the clinician, by not having to regurgitate the

patient's information in triplicate, could be utilized performing other billable

services.

Medicare makes a statement (paraphrased) that they will not dictate the actual

chart format as long as all the required information is present. It is my

opinion that JCAHO should do the same.

Respectfully,

Jon Mark Pleasant, PT

Methodist Medical Center

> > >

> > > Eileen:

> > >

> > > The patient summary list is form that lists a summary of diagnosis,

surgical interventions, medications and drug allergies. It needs to be filled

out ASAP and no later than 3 visits. To comply with this, we fill it out upon

evaluation. They will not accept your evaluation that lists all this. The

requirement is to ensure that in case of emergency, there is a summary of the

medical history and the current condition you are treating the patient and also

provide a structured process so you can update any new problems or conditions.

Feel free to call me and I can email you our form that works for this and had

passed well with JC survey.

> > >

> > > Agnes V. Papa, PT

> > > Director of Rehabilitation

> > > Bert Fish Medical Center

> > > fax

> > > This e-mail or the documents accompanying this e-mail contain information

that may be confidential and/or privileged. It may also be prohibited from

disclosure under applicable law. The opinions expressed are those of the sender

and do not necessarily represent the policy or positions of Bert Fish Medical

Center. The information is intended to be for the use of the individual or

entity named on this transmission. If you are not the intended recipient, be

aware that any disclosure, copying, distribution or use of the contents of this

information is without authorization and is prohibited. If you have received

this e-mail in error, please notify us immediately so that we can take action to

correct the problem.

> > >

> > > ________________________________

> > > From:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTM\

anager%40yahoogroups.com>] On Behalf Of Eileen Casey

> > > Sent: Tuesday, April 12, 2011 2:52 PM

> > > To:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com>

> > > Subject: summary lists for hospital based outpatient rehab

> > >

> > >

> > >

> > >

> > > Good Afternoon,

> > >

> > > On a recent JCAHO survey we were cited for not having a " summary list "

> > > for each outpatient. Our initial evaluation form has documented PMH/PSH,

> > > medications, allergies that is completed on the first visit however our

> > > surveyor did not agree that this is a " summary list " .

> > >

> > > As we are a small rural hospital we do not have a full EMR so a summary

> > > list that is " readily available to all practitioners and updated

> > > whenever there is a change in diagnosis, medications or allergies and

> > > whenever a procedure is performed " per JCAHO is not in place.

> > >

> > > Has anyone else dealt with this situation? Any suggestions?

> > >

> > > Eileen Casey, PT

> > >

> > > Director of Rehab Services

> > >

> > > Brattleboro Memorial Hospital

> > >

> > > 17 Belmont Ave

> > >

> > > Brattleboro, VT 05301

> > >

> > >

> > >

> > > ecasey@<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@<mailto:ecasey%40bmhvt.org>>

> > >

> > > __________________________________________________________

> > >

> > > The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

> > > __________________________________________________________

> > >

> > >

[Guest guest]

Eileen,

We, too, received a recommendation by Joint Commission in our December

2010 survey for not having a summary list. We collected all of the data

on a couple of different forms, but the surveyor wanted it on one

form. We have since adopted a summary list that we are now using in

our six outpatient clinics. If you want to see it let me know and I'll

email it to you or we can talk if you want more info.

Mark Dwyer, PT, MHA

Director of Rehabilitation Services

Olathe Medical Center

Olathe, Kansas

markdwyer87@...

summary lists for hospital based outpatient rehab

<http://groups.yahoo.com/group/PTManager/message/51193;_ylc=X3oDMTJyOXVzbnJiBF9T\

Azk3MzU5NzE1BGdycElkAzExMDA3ODEEZ3Jwc3BJZAMxNzA1MDYxMzQ3BG1zZ0lkAzUxMTkzBHNlYwNk\

bXNnBHNsawN2bXNnBHN0aW1lAzEzMDI2OTQ5Nzg->

Posted by: " Eileen Casey " ecasey@...

<mailto:ecasey@...?Subject=%20Re%3A%20summary%20lists%20for%20hospital%20b\

ased%20outpatient%20rehab>

Tue Apr 12, 2011 12:20 pm (PDT)

Good Afternoon,

On a recent JCAHO survey we were cited for not having a " summary list "

for each outpatient. Our initial evaluation form has documented PMH/PSH,

medications, allergies that is completed on the first visit however our

surveyor did not agree that this is a " summary list " .

As we are a small rural hospital we do not have a full EMR so a summary

list that is " readily available to all practitioners and updated

whenever there is a change in diagnosis, medications or allergies and

whenever a procedure is performed " per JCAHO is not in place.

Has anyone else dealt with this situation? Any suggestions?

Eileen Casey, PT

Director of Rehab Services

Brattleboro Memorial Hospital

17 Belmont Ave

Brattleboro, VT 05301

[Guest guest]

Jon:

JC surveyors typically ask you to show then where you can find the patient

summary list. If you cannot show it in front of them in an appropriate time

(fast) , then to them it will mean that your staff cannot find it in time

either. All our documentation are in EMR with the exception of the patient

summary list which is still on paper and will be scanned upon discharge to the

system to put in EMR together with the signed care plans, patient questionnaires

and forms that we filled out for standardized testing. The therapist are so used

to it because we have been doing it for many years now that repetition is not an

issue. But the benefits of having someone find all medical history in one form

and medications, allergies is safe and efficient in times of emergency. And I do

agree that there needs to still be a system in place to put it in EMR ASAP (we

could do that by scanning if we have to chose not to till the patient gets

discharged) . For us, we have it in the back page of the hard chart so everyone

knows where to look, no searching needed. Have fun:)

Agnes V. Papa, PT

Director of Rehabilitation

Bert Fish Medical Center

fax

This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

________________________________

From: PTManager [mailto:PTManager ] On Behalf Of

jonmarkpleasant

Sent: Wednesday, April 13, 2011 8:31 PM

To: PTManager

Subject: Re: summary lists for hospital based outpatient rehab

Agnes,

I'm sure you would agree that rewriting the patient summary information in three

different locations is inefficient and does nothing to improve patient care.

It is my opinion that JCAHO creates pet projects such as this to make it easier

on themselves during their three day survey while not considering the increase

burden that is put on clinicians the other 1092 days (not including leap year).

At some point in the near future when we all will be utilizing EMRs, the patient

summary list will probably be accessed by selecting an appropriately labeled

tab. In other words, the JCAHO surveyor will have to search for it.

With this future EMR search in mind, I would like to suggest we apply this

search method to our present paper charts.

On the front page of your outpatient paper chart, you can simply have a " Search

Index " that directs the surveyor to the appropriate tab (ex. Assessment Tab)

where the patient summary list can be found. The patient summary information

(written by the patient/patient family member) could be conveniently attached to

the therapist's initial evaluation. This way, there is no need for the therapist

to rewrite this information on the evaluation AND on another patient summary

form. The therapist can add information to it in the event the patient's

situation changes.

In effect, you are conveniently directing the JCAHO surveyor to the information

they seek via your front page Search Index. The therapist and the JCAHO surveyor

are performing an old school search similar to how they will search when we are

all on EMRs in the near future.

The real time savings for the clinician, by not having to regurgitate the

patient's information in triplicate, could be utilized performing other billable

services.

Medicare makes a statement (paraphrased) that they will not dictate the actual

chart format as long as all the required information is present. It is my

opinion that JCAHO should do the same.

Respectfully,

Jon Mark Pleasant, PT

Methodist Medical Center

> > >

> > > Eileen:

> > >

> > > The patient summary list is form that lists a summary of diagnosis,

surgical interventions, medications and drug allergies. It needs to be filled

out ASAP and no later than 3 visits. To comply with this, we fill it out upon

evaluation. They will not accept your evaluation that lists all this. The

requirement is to ensure that in case of emergency, there is a summary of the

medical history and the current condition you are treating the patient and also

provide a structured process so you can update any new problems or conditions.

Feel free to call me and I can email you our form that works for this and had

passed well with JC survey.

> > >

> > > Agnes V. Papa, PT

> > > Director of Rehabilitation

> > > Bert Fish Medical Center

> > > fax

> > > This e-mail or the documents accompanying this e-mail contain information

that may be confidential and/or privileged. It may also be prohibited from

disclosure under applicable law. The opinions expressed are those of the sender

and do not necessarily represent the policy or positions of Bert Fish Medical

Center. The information is intended to be for the use of the individual or

entity named on this transmission. If you are not the intended recipient, be

aware that any disclosure, copying, distribution or use of the contents of this

information is without authorization and is prohibited. If you have received

this e-mail in error, please notify us immediately so that we can take action to

correct the problem.

> > >

> > > ________________________________

> > > From:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com><mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTM\

anager%40yahoogroups.com><mailto:PTManager%40yahoogroups.com>] On Behalf Of

Eileen Casey

> > > Sent: Tuesday, April 12, 2011 2:52 PM

> > > To:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com><mailto:PTManager%40yahoogroups.com>

> > > Subject: summary lists for hospital based outpatient rehab

> > >

> > >

> > >

> > >

> > > Good Afternoon,

> > >

> > > On a recent JCAHO survey we were cited for not having a " summary list "

> > > for each outpatient. Our initial evaluation form has documented PMH/PSH,

> > > medications, allergies that is completed on the first visit however our

> > > surveyor did not agree that this is a " summary list " .

> > >

> > > As we are a small rural hospital we do not have a full EMR so a summary

> > > list that is " readily available to all practitioners and updated

> > > whenever there is a change in diagnosis, medications or allergies and

> > > whenever a procedure is performed " per JCAHO is not in place.

> > >

> > > Has anyone else dealt with this situation? Any suggestions?

> > >

> > > Eileen Casey, PT

> > >

> > > Director of Rehab Services

> > >

> > > Brattleboro Memorial Hospital

> > >

> > > 17 Belmont Ave

> > >

> > > Brattleboro, VT 05301

> > >

> > >

> > >

> > > ecasey@<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@<mailto:ecasey%40bmhvt.org>>

> > >

> > > __________________________________________________________

> > >

> > > The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

> > > __________________________________________________________

> > >

> > >

[Guest guest]

Jon:

JC surveyors typically ask you to show then where you can find the patient

summary list. If you cannot show it in front of them in an appropriate time

(fast) , then to them it will mean that your staff cannot find it in time

either. All our documentation are in EMR with the exception of the patient

summary list which is still on paper and will be scanned upon discharge to the

system to put in EMR together with the signed care plans, patient questionnaires

and forms that we filled out for standardized testing. The therapist are so used

to it because we have been doing it for many years now that repetition is not an

issue. But the benefits of having someone find all medical history in one form

and medications, allergies is safe and efficient in times of emergency. And I do

agree that there needs to still be a system in place to put it in EMR ASAP (we

could do that by scanning if we have to chose not to till the patient gets

discharged) . For us, we have it in the back page of the hard chart so everyone

knows where to look, no searching needed. Have fun:)

Agnes V. Papa, PT

Director of Rehabilitation

Bert Fish Medical Center

fax

This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

________________________________

From: PTManager [mailto:PTManager ] On Behalf Of

jonmarkpleasant

Sent: Wednesday, April 13, 2011 8:31 PM

To: PTManager

Subject: Re: summary lists for hospital based outpatient rehab

Agnes,

I'm sure you would agree that rewriting the patient summary information in three

different locations is inefficient and does nothing to improve patient care.

It is my opinion that JCAHO creates pet projects such as this to make it easier

on themselves during their three day survey while not considering the increase

burden that is put on clinicians the other 1092 days (not including leap year).

At some point in the near future when we all will be utilizing EMRs, the patient

summary list will probably be accessed by selecting an appropriately labeled

tab. In other words, the JCAHO surveyor will have to search for it.

With this future EMR search in mind, I would like to suggest we apply this

search method to our present paper charts.

On the front page of your outpatient paper chart, you can simply have a " Search

Index " that directs the surveyor to the appropriate tab (ex. Assessment Tab)

where the patient summary list can be found. The patient summary information

(written by the patient/patient family member) could be conveniently attached to

the therapist's initial evaluation. This way, there is no need for the therapist

to rewrite this information on the evaluation AND on another patient summary

form. The therapist can add information to it in the event the patient's

situation changes.

In effect, you are conveniently directing the JCAHO surveyor to the information

they seek via your front page Search Index. The therapist and the JCAHO surveyor

are performing an old school search similar to how they will search when we are

all on EMRs in the near future.

The real time savings for the clinician, by not having to regurgitate the

patient's information in triplicate, could be utilized performing other billable

services.

Medicare makes a statement (paraphrased) that they will not dictate the actual

chart format as long as all the required information is present. It is my

opinion that JCAHO should do the same.

Respectfully,

Jon Mark Pleasant, PT

Methodist Medical Center

> > >

> > > Eileen:

> > >

> > > The patient summary list is form that lists a summary of diagnosis,

surgical interventions, medications and drug allergies. It needs to be filled

out ASAP and no later than 3 visits. To comply with this, we fill it out upon

evaluation. They will not accept your evaluation that lists all this. The

requirement is to ensure that in case of emergency, there is a summary of the

medical history and the current condition you are treating the patient and also

provide a structured process so you can update any new problems or conditions.

Feel free to call me and I can email you our form that works for this and had

passed well with JC survey.

> > >

> > > Agnes V. Papa, PT

> > > Director of Rehabilitation

> > > Bert Fish Medical Center

> > > fax

> > > This e-mail or the documents accompanying this e-mail contain information

that may be confidential and/or privileged. It may also be prohibited from

disclosure under applicable law. The opinions expressed are those of the sender

and do not necessarily represent the policy or positions of Bert Fish Medical

Center. The information is intended to be for the use of the individual or

entity named on this transmission. If you are not the intended recipient, be

aware that any disclosure, copying, distribution or use of the contents of this

information is without authorization and is prohibited. If you have received

this e-mail in error, please notify us immediately so that we can take action to

correct the problem.

> > >

> > > ________________________________

> > > From:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com><mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTM\

anager%40yahoogroups.com><mailto:PTManager%40yahoogroups.com>] On Behalf Of

Eileen Casey

> > > Sent: Tuesday, April 12, 2011 2:52 PM

> > > To:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com><mailto:PTManager%40yahoogroups.com>

> > > Subject: summary lists for hospital based outpatient rehab

> > >

> > >

> > >

> > >

> > > Good Afternoon,

> > >

> > > On a recent JCAHO survey we were cited for not having a " summary list "

> > > for each outpatient. Our initial evaluation form has documented PMH/PSH,

> > > medications, allergies that is completed on the first visit however our

> > > surveyor did not agree that this is a " summary list " .

> > >

> > > As we are a small rural hospital we do not have a full EMR so a summary

> > > list that is " readily available to all practitioners and updated

> > > whenever there is a change in diagnosis, medications or allergies and

> > > whenever a procedure is performed " per JCAHO is not in place.

> > >

> > > Has anyone else dealt with this situation? Any suggestions?

> > >

> > > Eileen Casey, PT

> > >

> > > Director of Rehab Services

> > >

> > > Brattleboro Memorial Hospital

> > >

> > > 17 Belmont Ave

> > >

> > > Brattleboro, VT 05301

> > >

> > >

> > >

> > > ecasey@<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@<mailto:ecasey%40bmhvt.org>>

> > >

> > > __________________________________________________________

> > >

> > > The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

> > > __________________________________________________________

> > >

> > >

[Guest guest]

Jon:

JC surveyors typically ask you to show then where you can find the patient

summary list. If you cannot show it in front of them in an appropriate time

(fast) , then to them it will mean that your staff cannot find it in time

either. All our documentation are in EMR with the exception of the patient

summary list which is still on paper and will be scanned upon discharge to the

system to put in EMR together with the signed care plans, patient questionnaires

and forms that we filled out for standardized testing. The therapist are so used

to it because we have been doing it for many years now that repetition is not an

issue. But the benefits of having someone find all medical history in one form

and medications, allergies is safe and efficient in times of emergency. And I do

agree that there needs to still be a system in place to put it in EMR ASAP (we

could do that by scanning if we have to chose not to till the patient gets

discharged) . For us, we have it in the back page of the hard chart so everyone

knows where to look, no searching needed. Have fun:)

Agnes V. Papa, PT

Director of Rehabilitation

Bert Fish Medical Center

fax

This e-mail or the documents accompanying this e-mail contain information that

may be confidential and/or privileged. It may also be prohibited from disclosure

under applicable law. The opinions expressed are those of the sender and do not

necessarily represent the policy or positions of Bert Fish Medical Center. The

information is intended to be for the use of the individual or entity named on

this transmission. If you are not the intended recipient, be aware that any

disclosure, copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this e-mail in

error, please notify us immediately so that we can take action to correct the

problem.

________________________________

From: PTManager [mailto:PTManager ] On Behalf Of

jonmarkpleasant

Sent: Wednesday, April 13, 2011 8:31 PM

To: PTManager

Subject: Re: summary lists for hospital based outpatient rehab

Agnes,

I'm sure you would agree that rewriting the patient summary information in three

different locations is inefficient and does nothing to improve patient care.

It is my opinion that JCAHO creates pet projects such as this to make it easier

on themselves during their three day survey while not considering the increase

burden that is put on clinicians the other 1092 days (not including leap year).

At some point in the near future when we all will be utilizing EMRs, the patient

summary list will probably be accessed by selecting an appropriately labeled

tab. In other words, the JCAHO surveyor will have to search for it.

With this future EMR search in mind, I would like to suggest we apply this

search method to our present paper charts.

On the front page of your outpatient paper chart, you can simply have a " Search

Index " that directs the surveyor to the appropriate tab (ex. Assessment Tab)

where the patient summary list can be found. The patient summary information

(written by the patient/patient family member) could be conveniently attached to

the therapist's initial evaluation. This way, there is no need for the therapist

to rewrite this information on the evaluation AND on another patient summary

form. The therapist can add information to it in the event the patient's

situation changes.

In effect, you are conveniently directing the JCAHO surveyor to the information

they seek via your front page Search Index. The therapist and the JCAHO surveyor

are performing an old school search similar to how they will search when we are

all on EMRs in the near future.

The real time savings for the clinician, by not having to regurgitate the

patient's information in triplicate, could be utilized performing other billable

services.

Medicare makes a statement (paraphrased) that they will not dictate the actual

chart format as long as all the required information is present. It is my

opinion that JCAHO should do the same.

Respectfully,

Jon Mark Pleasant, PT

Methodist Medical Center

> > >

> > > Eileen:

> > >

> > > The patient summary list is form that lists a summary of diagnosis,

surgical interventions, medications and drug allergies. It needs to be filled

out ASAP and no later than 3 visits. To comply with this, we fill it out upon

evaluation. They will not accept your evaluation that lists all this. The

requirement is to ensure that in case of emergency, there is a summary of the

medical history and the current condition you are treating the patient and also

provide a structured process so you can update any new problems or conditions.

Feel free to call me and I can email you our form that works for this and had

passed well with JC survey.

> > >

> > > Agnes V. Papa, PT

> > > Director of Rehabilitation

> > > Bert Fish Medical Center

> > > fax

> > > This e-mail or the documents accompanying this e-mail contain information

that may be confidential and/or privileged. It may also be prohibited from

disclosure under applicable law. The opinions expressed are those of the sender

and do not necessarily represent the policy or positions of Bert Fish Medical

Center. The information is intended to be for the use of the individual or

entity named on this transmission. If you are not the intended recipient, be

aware that any disclosure, copying, distribution or use of the contents of this

information is without authorization and is prohibited. If you have received

this e-mail in error, please notify us immediately so that we can take action to

correct the problem.

> > >

> > > ________________________________

> > > From:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com><mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTM\

anager%40yahoogroups.com><mailto:PTManager%40yahoogroups.com>] On Behalf Of

Eileen Casey

> > > Sent: Tuesday, April 12, 2011 2:52 PM

> > > To:

PTManager <mailto:PTManager%40yahoogroups.com><mailto:PTManager%4\

0yahoogroups.com><mailto:PTManager%40yahoogroups.com>

> > > Subject: summary lists for hospital based outpatient rehab

> > >

> > >

> > >

> > >

> > > Good Afternoon,

> > >

> > > On a recent JCAHO survey we were cited for not having a " summary list "

> > > for each outpatient. Our initial evaluation form has documented PMH/PSH,

> > > medications, allergies that is completed on the first visit however our

> > > surveyor did not agree that this is a " summary list " .

> > >

> > > As we are a small rural hospital we do not have a full EMR so a summary

> > > list that is " readily available to all practitioners and updated

> > > whenever there is a change in diagnosis, medications or allergies and

> > > whenever a procedure is performed " per JCAHO is not in place.

> > >

> > > Has anyone else dealt with this situation? Any suggestions?

> > >

> > > Eileen Casey, PT

> > >

> > > Director of Rehab Services

> > >

> > > Brattleboro Memorial Hospital

> > >

> > > 17 Belmont Ave

> > >

> > > Brattleboro, VT 05301

> > >

> > >

> > >

> > > ecasey@<mailto:ecasey%40bmhvt.org>

<mailto:ecasey@<mailto:ecasey%40bmhvt.org>>

> > >

> > > __________________________________________________________

> > >

> > > The information contained in, or attached to, this e-mail, may contain

confidential information and is intended solely for the use of the individual or

entity to whom it is addressed and may be subject to legal privilege. If you

have received this e-mail in error you should notify the sender immediately by

reply e-mail, delete the message from your system and notify your system

manager. Please do not copy it for any purpose, or disclose its contents to any

other person. The views or opinions presented in this e-mail are solely those of

the author and do not necessarily represent those of the company. The recipient

should check this e-mail and any attachments for the presence of viruses. The

company accepts no liability for any damage caused, directly or indirectly, by

any virus transmitted in this email.

> > > __________________________________________________________

> > >

> > >

[Guest guest]

To All who responded to my inquiry:

Thank you all so much for sharing your experiences with this requirement

as well as generously sharing your documentation.

Eileen Casey, PT

Brattleboro Memorial Hospital

17 Belmont Ave

Brattleboro, VT 05301

________________________________

From: PTManager [mailto:PTManager ] On

Behalf Of jonmarkpleasant

Sent: Wednesday, April 13, 2011 8:31 PM

To: PTManager

Subject: Re: summary lists for hospital based outpatient

rehab

Agnes,

I'm sure you would agree that rewriting the patient summary information

in three different locations is inefficient and does nothing to improve

patient care.

It is my opinion that JCAHO creates pet projects such as this to make it

easier on themselves during their three day survey while not considering

the increase burden that is put on clinicians the other 1092 days (not

including leap year).

At some point in the near future when we all will be utilizing EMRs, the

patient summary list will probably be accessed by selecting an

appropriately labeled tab. In other words, the JCAHO surveyor will have

to search for it.

With this future EMR search in mind, I would like to suggest we apply

this search method to our present paper charts.

On the front page of your outpatient paper chart, you can simply have a

" Search Index " that directs the surveyor to the appropriate tab (ex.

Assessment Tab) where the patient summary list can be found. The patient

summary information (written by the patient/patient family member) could

be conveniently attached to the therapist's initial evaluation. This

way, there is no need for the therapist to rewrite this information on

the evaluation AND on another patient summary form. The therapist can

add information to it in the event the patient's situation changes.

In effect, you are conveniently directing the JCAHO surveyor to the

information they seek via your front page Search Index. The therapist

and the JCAHO surveyor are performing an old school search similar to

how they will search when we are all on EMRs in the near future.

The real time savings for the clinician, by not having to regurgitate

the patient's information in triplicate, could be utilized performing

other billable services.

Medicare makes a statement (paraphrased) that they will not dictate the

actual chart format as long as all the required information is present.

It is my opinion that JCAHO should do the same.

Respectfully,

Jon Mark Pleasant, PT

Methodist Medical Center

> > >

> > > Eileen:

> > >

> > > The patient summary list is form that lists a summary of

diagnosis, surgical interventions, medications and drug allergies. It

needs to be filled out ASAP and no later than 3 visits. To comply with

this, we fill it out upon evaluation. They will not accept your

evaluation that lists all this. The requirement is to ensure that in

case of emergency, there is a summary of the medical history and the

current condition you are treating the patient and also provide a

structured process so you can update any new problems or conditions.

Feel free to call me and I can email you our form that works for this

and had passed well with JC survey.

> > >

> > > Agnes V. Papa, PT

> > > Director of Rehabilitation

> > > Bert Fish Medical Center

> > > fax

> > > This e-mail or the documents accompanying this e-mail contain

information that may be confidential and/or privileged. It may also be

prohibited from disclosure under applicable law. The opinions expressed

are those of the sender and do not necessarily represent the policy or

positions of Bert Fish Medical Center. The information is intended to be

for the use of the individual or entity named on this transmission. If

you are not the intended recipient, be aware that any disclosure,

copying, distribution or use of the contents of this information is

without authorization and is prohibited. If you have received this

e-mail in error, please notify us immediately so that we can take action

to correct the problem.

> > >

> > > ________________________________

> > > From: PTManager

<mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com><mailto:PTManager%40yahoogroups.com>

[mailto:PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com><mailto:PTManager%40yahoogroups.com>

] On Behalf Of Eileen Casey

> > > Sent: Tuesday, April 12, 2011 2:52 PM

> > > To: PTManager <mailto:PTManager%40yahoogroups.com>

<mailto:PTManager%40yahoogroups.com><mailto:PTManager%40yahoogroups.com>

> > > Subject: summary lists for hospital based outpatient

rehab

> > >

> > >

> > >

> > >

> > > Good Afternoon,

> > >

> > > On a recent JCAHO survey we were cited for not having a " summary

list "

> > > for each outpatient. Our initial evaluation form has documented

PMH/PSH,

> > > medications, allergies that is completed on the first visit

however our

> > > surveyor did not agree that this is a " summary list " .

> > >

> > > As we are a small rural hospital we do not have a full EMR so a

summary

> > > list that is " readily available to all practitioners and updated

> > > whenever there is a change in diagnosis, medications or allergies

and

> > > whenever a procedure is performed " per JCAHO is not in place.

> > >

> > > Has anyone else dealt with this situation? Any suggestions?

> > >

> > > Eileen Casey, PT

> > >

> > > Director of Rehab Services

> > >

> > > Brattleboro Memorial Hospital

> > >

> > > 17 Belmont Ave

> > >

> > > Brattleboro, VT 05301

> > >

> > >

> > >

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