Service Specific Documentation Guidelines. Service Area: Inpatient MSK / Amputee Rehab October 2007

Transcription

1 1. Standards of Practice Service Specific Documentation Guidelines Service Area: Inpatient MSK / Amputee Rehab October 2007 Informed Consent for Assessment and Treatment Check box on assessment form. 2. Charting Procedures Referral Source - Physiatrists - Physical medicine residents - Clinical clerks - Self-referral Referrals are processed depending on the service and may be found on the physician s order sheet. Within twenty-four hours of receiving an order, the physiotherapist should commence assessment and treatment. In the event of an admission late Friday afternoon, full assessment and treatment is initiated the following full working day. 3. Assessment The Amputee Assessment Form or the Rehab Inpatient Musculoskeletal/ Trauma Assessment Form (as indicated by the condition) are used for new assessments. The completed forms are kept in the Allied Health section of the chart. Within twenty-four hours of the initial visit, documentation on the chart should include: date patient consent whether assessment initiated/completed parameters of initial treatment (may be on initial assessment if complete within 24 hours) Full assessment should be completed within five working days of admission. When the initial assessment cannot be completed due to time constraints or patient intolerance this should be noted in the chart and any subsequent data collected should be added to the assessment sheet and dated.

2 History and Subjective Information Physical Findings/Objective Data As listed on the assessment forms. In addition the chart may contain: Main complaint/reason for referral Pain behavior Impact of symptoms on ADL, work, social and leisure activities Exercise History and tolerance Description of mobility aids and equipment As listed on the assessment form. In addition, the chart may contain relevant data on any/all of the following: Communication Cognition Perception Respiratory Status Articular Status - Active ROM - Passive ROM - Joint Swelling Edema Skin Condition Motor Function - Manual Muscle Test - Tone Exercise Tolerance Coordination Posture Balance - Static & Dynamic - Berg Balance Test Functional Mobility - Bed Mobility - Bed/Wheelchair Transfer Status - Floor to Stand Transfer - Wheelchair Safety - Wheelchair Skills - Ambulation Status (outdoors, curb, stairs, ramp) Locomotion - Gait Analysis - Ambulation Profile - Timed Up and Go - Timed Walk It is recognized that not all categories need to be tested on each patient. A line should be drawn though the blank area on the assessment form with the notation N/A (not applicable) or N/T (not tested).

3 - Inpatient transfer to Rehab site from within the QEII Health Sciences Centre Full assessment is not required if a transfer note is completed at the acute care site and contains all appropriate information (current status, treatment summary, and goals for further therapy). Documentation by the Rehabilitation Site physiotherapist in this instance should be in the progress section of the chart and titled Physiotherapy Initial Assessment. This note should include the following: Patient consent to assessment and treatment State that a full physiotherapy assessment and transfer note has already been completed and reviewed Documentation of any changes in status since transfer Long term goals List of limiting factors/problem list Treatment plan Parameters of initial treatment. 4. Analysis Outcome Measures Used Outcome measures may include: Assessment Findings Berg Balance Score Ambulation Profile Timed Ambulation Timed Up & Go Bed Mobility Profile The program also utilizes the CIHI FIM scoring as a Rehab Site outcome measure. The CIHI should be completed within 72 hours of admission. Problem List Documentation of Goals The patient chart should contain a logical analysis of the assessment findings in the form of a problem list. Limiting factors identified may be physical, medical, social, cognitive, and perceptual or communication factors which influence outcome. The physiotherapist and patient establish the Treatment Goal(s) taking into account the patient needs and limitations. Goals should be measurable, realistic and achievable within a reasonable time frame and documented in the Assessment form or initial physiotherapy progress note.

4 Team conference will have an estimated date of discharge 5. Treatment Documentation of Treatment Plan A treatment plan is established to address the patient s needs and to achieve the treatment goal(s). Details of specific treatment are noted in full e.g. treatment parameters for modalities and exercise equipment, description of exercises including repetitions, position, weights, etc. and any education provided. A Home Program Summary Sheet or the Endurance Activity Record (EAR) sheet may be used to record a description of therapeutic intervention and exercises. The Home Program Summery if used is placed in the Allied Health section of the chart. A summary of the Endurance Activity Record will be included in the discharge note as the EAR is not placed on the chart. 6. Progress Notes Frequency A progress note shall be written at least every five working days or if any change in the patient s status is noted. The weekly integrated team conference form may be considered a weekly progress note if it contains sufficient information concerning patient s status and physiotherapy plans. Content Progress notes are to be documented in the progress section. The format may be SOAP, paragraph form, or point form. The progress note should include the following information: Current status Response to treatment Any addition/changes to treatment Progress toward goals Reassessment/problem list New goals if appropriate Plan Any addition/changes to treatment are recorded in full. PCVC (precautions, contraindications explained, verbal consent received) should be noted when adding to, or changing modality or acupuncture treatments.

5 If a patient s active treatment status has been decreased to a maintenance program, a treatment note that describes the therapy and frequency should be documented once a week. If there is any change in status, a progress note should be documented. 7. Discharges D/C Summary All documentation should be completed within 24 hours of the patient s discharge. The discharge section of the Amputee Assessment Form or the ROM and Strength section of the Musculoskeletal/ Trauma Assessment Forms is completed. For the Musculoskeletal/Trauma patients The Rehab Inpatient Musculoskeletal Discharge form is completed and placed in the Allied Health section of the chart. For Amputee patients -The Amputee Discharge Summary or Post Initial Gait Training form is completed and is placed in the Allied Health section of the chart. A discharge note may be written in place of the Amputee Summary and should include: date of initial treatment and status treatment summary response to treatment current status achievement of long term goals recommendations / arrangements for follow-up specifics of home exercise program and patient/family education The discharge note may be written in the progress notes of the chart or can be placed in the Allied Health section. The Amputee File Card should be updated for all amputee patients and placed in the small file box.