PURPOSE OF DOCUMENTATION

·        OT/PT have reduced documenting. OT’s/PT’s are required to improve writing skills that reflect objectivity, clinical accuracy, conciseness, completeness and a system of record keeping that is efficient.

·        Documentation is very very important part of OT/PT services and

                 i.            Provides administrative control.

              ii.            Complies with law and aids in litigation.

              iii.            Provides clear objective data about the patient on which future treatment can be based.

              iv.            Communicating progress to the physician or other health care professionals concerned.

                v.            Provides justification for the records of the treatment.

               vi.            Interprets treatment programme to the patient and concerned.

              vii.            Facilitates continuity of the treatment when the staff changes occur.

             viii.            Facilitate in service training and student education program.

                ix.            Evaluates effectiveness of the OT/PT intervention.

                 x.            Provides data for research and advancement of the professionals of OT/PT.  

DO’s AND DON'Ts FOR DOCUMENTATION IN OT/PT

    Do’s: -

1. Be truthful, accurate and complete.

2. Write record as soon as treatment is rendered.

3. Date and sign all records.

4. Use Specific terms.

5. Make factual statements.

6. Record broken appointments with reasons.

7. Record attempts to re-schedule.

    Don’ts

1. Change a record only after ascertaining the fact without clarifying when and why the change was made? What the nature of change was?

2. Criticize another healthcare provider as a part of the record.

3. Make judgmental statement about the patient and or his family.

4. Assume that the record will not be open to scrutiny by patient, family, lawyers and court.

Documentation Abuse when it is

• Malpractice Records
• Negligence and negligent recordings

            Affect patient as: - Loss to follow up and report

• Treatment record missing.

• Side effects/implications of the treatment effects

• Patient does not comply with therapist’s instructions

• Diagnostic judgment was wrong.

• Treatment outcomes bad even with best efforts put in.

• Therapist faces a lawsuit.

  Malpractice if

• Negligence in duty

• Poor standard of care

• Causes and damages to the health of patient

 

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