Documentation

[Guest guest]

>> 1. What is the biggest issue at your facility concerning documentation

from

>> a) management's per perspective

To be sure that what therapists document paints a clear picture of the

patient's case and also justifies the provision of therapy services to

third party payors.

>> the staff therapist's perspective?

Brevity and lack of duplication. I believe therapists are still more

concerned with treating patients than with hassling with paperwork,

therefore, sometimes not enough time is spent on documentation (or can be

spent depending on caseload). I like the idea of moving to computerized

documentation for two reasons:

--> is easier to pull up past information, making note completion

quicker

--> is legible

--> can have " required fields " where therapists MUST document -->

avoids the " forget " factor

>> 2. What resources are used to resolve these issues?

We and many other facilties are utilizing computers to make things better.

While the learning curve for computers can be steep, the ultimate payoff

will hopefully be worth it in the form of decreased time demands, improved

readibility, and improved standardization.

>> I'm studying the topic of documentation among healthcare workers and

third party payors ( primarily managed care >> organizations) and some

interesting trends are becoming very apparent.

I would be interested to hear about the trends you are discovering.

Mark Dwyer, MHA, PT

Manager of Rehabilitation Services

Bethany Medical Center

51 North 12th Street

Kansas City KS 66102

(Phone)

(FAX)

73614.2302@...

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