Supervision issue

December 15, 2004

According to the PT Guide to Practice, all d/c summaries written by

the PTA should be approved and authorized by the evaluating PT.

However, it doesn't spell out specifically how this can be done

(verbal authorization that is documented, co-signature on the d/c,

etc). Because we would rather err on the side of caution, our acute

care therapy area has implemented the following:

1) If an infrequent PRN PT performs the evaluation, it is handed off

to a PT that is part of the core staff for the first treatment prior

to be turned over to the PTA. This enables " face time " with the

patient so that the core staff PT feels comfortable with the plan of

care, providing the necessary supervision, and eventually co-signing

the d/c summary.

2) If an infrequent PRN PT performs the evaluation and the patient is

discharged before any follow-up treatment takes place, it is the duty

of the PRN PT that did the evaluation to " close out " the plan of care

with a brief d/c summary.

Here are the problems with the above: Our acute care PTs sometimes

receive 25 referrals in one day. We are already having difficulty

getting our patients seen as often as needed, in part, due to the PT

positions that we currently have open. According to our guideline, it

means that the core PT staff not only have to address new evaluations,

but also the first treatment as well. This has created a situation

where additional patient treatments are missed, physicians and case

management are upset, and it has also had a negative impact on our

acute care productivity. I'm interested in how other hospitals have

dealt with this issue. Any feedback would be much appreciated.

Thank you,

Curtis

December 16, 2004

Dear Curtis,

I can feel your pain--we were having a lot of the same issues. I have

included a post from a while back (July 31, 2003) about this topic. As an

update, we have been very happy with the decision that we made to stop doing

acute care d/c summaries (except if they are discharged from PT services

before they leave the hospital). We have also made appropriate changes to

our policy/procedure manual to represent our practice. I don't want anyone

to do anything that they believe is incorrect, but we feel that the process

AND the patient care (as well as our daily documentation content) have

improved since the change.

Hope this helps...

Have a very happpy Holiday,

:-) Martha

Hi Ken,

Thanks for the rules and guidelines. We have been studying them over the

last year, as well as the laws and JCAHO requirements. Believe me, I was

the discharge summary advocate until the end, because I am one that likes

closure (even though I am the only one who benefits from it!). However, we

finally looked deep to define the purpose of the discharge summary in the

acute setting. We had streamlined our process and worked on making the

discharge summary an effective tool by making part of it carboned from the

eval, making it double as a last note, etc. (I mailed out a sample of our

eval form to a few that were interested) And we were effective in getting

approximately 80% of the discharge summaries in the chart the day the

patient discharged from the hospital. However, many times the chart had

already been copied by SWS and/or faxed to the patient's next destination

before we could complete the discharge summary. And the other 20% were

those pesky people who leave in the middle of the night and on the weekends!

For those patients, a lot of times we were having to go to medical records

to complete a proper discharge summary.

Anyway, the part I forgot to leave out of my last post when I said we

decided to stop the discharge summaries was that we changed our

documentation for our daily notes. We now require the use of pre-printed

notes that many therapists had already been utilizing. These notes cue the

therapist to comment on goal status, communication to nsg./SWS/Care

Coordinators, equipment needed, discharge plan, pain levels (all those great

JCAHO requirements that we need to be commenting on anyway). In this way we

are like Lori in MI, in that we pretend that we may never see the patient

again! Another perk is that since we are not calling our daily notes a

" discharge summary " , it is o.k. that a P.T.A.s note is the last one entered

in the chart.

This way, we feel like the information that is most helpful for the next

venue of care is included in our daily notes, and it forces us to always

make sure that the patient's discharge plan is accurate and appropriate

(especially since the d/c plan changes from day-to-day in the acute

setting). And again, we complete a discharge summary for patients that are

discharged from therapy before they leave the hospital. In all other cases,

we feel that the physician's discharge summary is more appropriate, since

they are the caregivers that are actually ordering the discharge.

We are still in the early phases of this process (only 2 weeks in), and we

have a JCAHO visit coming up at the end of the year. So, I would appreciate

any more feedback, and I will do the same after our accreditation.

Have a great day,