Documentation
Why is Documentation in Healthcare Important?
Documentation is a critical vehicle for conveying essential clinical information about each patient’s diagnosis, treatment, and outcomes and for communication between clinicians and payers.
Clinicians must efficiently respond to the questions that payers are asking about each service: Is it medically necessary? It is a service requiring the knowledge and skills of the professional? Are the goals and treatment functionally relevant? How does this service add value to the patient’s interdisciplinary care and overall health?
In short, documentation:
- Aids the sharing of relevant information and multidisciplinary team communication
- Aids informed decision making for patient management
- Improves availability of data for route cause analysis in the investigation of serious incidents
- Aids targeting of diagnostic and treatment plans without unnecessary repetition
- “If you did not write it down, it did not happen.”
Types of documentation (i.e. evaluation, standardized assessments, daily notes, re-evaluation, discharge, etc)
Evaluation
The evaluation report typically is a summary of the evaluation process, any resulting diagnosis, and a plan for service and may include the following:
- Reasons for referral
- Case history including prior level of function (PLOF), medical complexities, and comorbidities
- Standardized and/or non standardized methods of evaluation
- Diagnosis
- Analysis and integration of information to develop prognosis, including outcomes measures and projected outcomes
- Recommendation including referrals to other professionals as needed and plan of care.
Treatment
A treatment note is a record of a treatment session that typically includes the following information regarding the treatment session:
- Date
- Location
- Patient response
- Objective data on progress toward functional goals with comparison to prior sessions
- Skilled services provided (materials and strategies, patient/family education, analysis and assessment of patient performance, modification for progression of treatment)
- Session length and/or start up time
Progress Note
Progress notes are written at intervals that may be stipulated by the payer or the facility and report progress on long and short term goals.
- Number of sessions, location, attendance
- Patient response, including home programming
- Skilled services provided
- Objective measures of progress toward functional goals
- Changes to the goals or plan of care, if appropriate
Discharge Summary
Discharge summary notes are prepared at the conclusion of treatment and typically include:
- Dates of treatment
- Goals and progress toward goals
- Treatment provided
- Objective measures (pre and post evaluation)
- Functional statues (ICF)
- patient/caregiver education provided
- Reason for discharge
- Recommendations for follow up
American Health Information Management Association. (n.d.). Fundamentals of the legal health record and designated record set. Retrieved from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048604.hcsp?dDocName=bok1_048604.
American Speech-Language-Hearing Association. (n.d.). International Classification of Functioning, Disability and Health (ICF). Retrieved from www.asha.org/slp/icf/.
American Speech-Language-Hearing Association. (2010b). Issues in ethics: Representation of services for insurance reimbursement, funding, or private payment. Retrieved from www.asha.org/Practice/ethics/misrepresentation-of-Services/.
Centers for Medicare and Medicaid Services. (2014r-c). Medicare benefit policy manual, chapter 15, section 220.2B. Retrieved from www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf.
Mathioudakis, A., Rousalova, I., Gagnat, A. A., Saad, N., & Hardavella, G. (2016). How to keep good clinical records. Breathe (Sheffield, England), 12(4), 369–373. https://doi.org/10.1183/20734735.018016