Purposes of Documentation
State and Federal law requirement recording health care provided. Facilities have policies that employees have to follow.
Legal Record
What components must be met for documentation to use disablement language.
Mentions impairments, functional limitation, and disabilities.
Comparing performance along with changes in patient status
assessment
Tells others how the patient functions and what their needs are.
Communication
Which characteristic of documentation mentions using the same format or headings?
consistent
Tests and measures. Impairment data, ROM, MMT, sensation, balance, functional status, interventions/education provided.
Objective
provides outcome data for evidence based practice
research
Which characteristic of documentation mentions needing to be specific to and effective for patient's condition
Reasonable and necessary intervention
Future treatment: adjustments/progression and referring to another clinician.
Plan
Timely documentation is critical. What best describes timely documentation
Documenting details within departmental guidelines.
Which characteristic of documentation mentions linking subjective/objective info with impairments/functional problems and goals. It is also indicating rational.
Indicates clinical decision making process
What the patient says, history, complaints, response to previous/current treatment, compliance with home program.
Subjective