I write entirely to find out what I'm thinking, what I'm looking at, what I see and what it means. — Joan Didion
*Mr. Ketterman's Case
Mr. Ketterman has so many issues that we are addressing. I want to be able to keep track of them all and I would like to be able to use what I learn from his care to help me with future patients. How can I manage this in my busy day? (See Appendix for Mr. Ketterman's health history.)
In Section III, we discussed identifying, assessing, and applying, as appropriate, evidence from the research literature to decisions about patient care. Yet, it is apparent that the research literature does not hold all the answers to all the questions we have about patient care. In Chapter 19, Drs. Bise and Delitto discuss an approach that uses the data generated in everyday care as a source of evidence. This approach, as with many evidence based activities, relies on documentation to be successful.
The goals of this chapter are to examine the multiple purposes of documentation and how these purposes may be met in producing accurate and useful documentation about a patient's condition. Thus, improved documentation can become a source of evidence that aids in decision making.
The patient/client record serves multiple purposes. According to the American Health Information Management Association (AHIMA), documentation has many purposes. For most clinicians, most of the time, the primary purpose of documentation is to provide a basis for clinical reasoning in planning care and assessing its success for the individual patient. Ideally, the patient/client record also serves as a communication tool for providers involved in the care and supports patient/client care delivery. Appropriate and meaningful documentation is important to support optimal decision making, to minimize risk, to promote continuity of care, and to determine the best plan of care for the patient/client.
Documentation is also a mandatory practice, subject to applicable jurisdictional and regulatory requirements. There are specific legal requirements about when and how to document patient care and charting errors. There are additional requirements for signature and other means to demonstrate the authenticity of the record. Payment for services is justified through documentation in the patient/client record. Different payment sources have specific mandates for documentation to justify both approval for services and to determine which, if any, services are eligible for payment.
All of these purposes matter in patient care, but the last one, a means for data collection and retrieval, may be the most important in terms of evidence based practice. When the clinical record contains standardized information, then these data can be retrieved and analyzed, both within and across practices. Secondary purposes are education, regulation (compliance and accreditation), research, policy making (allocating resources and business planning), and industry needs (including research and development).1
Standards for Quality in Documentation
AHIMA2 has defined comprehensive guidelines the patient record should meet if it is to serve as a basis for data collection through the collection of high-quality data. The characteristics are:
The purposes for which documentation is currently used extend beyond the reasons cited above and include risk assessment and management, quality assessment and improvement, peer review, and productivity measurement. When taking the manifold purposes of documentation into consideration, the task of documenting clearly, correctly, comprehensively, and meaningfully becomes even more important.
Documentation is defined in the Guide to Physical Therapist Practice3 as "any entry into the client record, such as a consultation report, initial examination report, progress note, flow sheet/checklist that identifies the care/service provided, re-examination, or summation of care." The American Physical Therapy Association gives general guidelines in its Guidelines for Physical Therapy Documentation that expand on specific elements that may be included. (The Guidelines may be found at www.APTA.org and at the F.A. Davis Web site for this book.) Documentation is a complex process that has many discrete parts. The Guidelines provide both lists of the various types of documentation that are seen in physical therapy and guidance for the standards that should be used in creating them.3 Standards include the need for clear authentication as to the physical therapist of record for the patient. Table 18.1 shows some of the many different kinds of documents created in the physical therapy record.
Table 18.1Purposes of Documentation and Elements Needing Documentation in the Physical Therapy Record ||Download (.pdf) Table 18.1 Purposes of Documentation and Elements Needing Documentation in the Physical Therapy Record
|Purpose of Documentation ||Essential elements in documentation |
|Initial Examination and Evaluation || |
Selection and administration of appropriate tests and measures
Plan of care
|Continuation of Care || |
Changes in patient/client status
Responses to interventions
Interpretation of findings
Revisions to the plan of care
|Summation of the Episode of Care || |
Criteria for discharge
Current physical/functional status
Degree of achievement of anticipated goals and expected outcomes
Reasons for goals and outcomes not being achieved
Discharge plan related to patients'/clients' continuing care
BARRIERS TO QUALITY DOCUMENTATION
If all documentation possessed the characteristics discussed above, we would be able to readily use it for developing evidence about the success of care. But there are disparities in much of the physical therapy documentation that preclude it from serving as a meaningful database. Practitioners, including physical therapists, often complain about the time needed to complete documentation as a primary reason for not producing documentation of the best quality.4,5,6,7,8,9 Several other reasons are also apparent, as are discussed later.
Current documentation commonly does not address all the appropriate elements listed in the APTA Guidelines. The examination may be limited to the identification of impairments and functional loss and may lack a meaningful, complete evaluation, diagnosis, and prognosis. Throughout the continuum of care, documentation commonly focuses on identifying impairments and listing interventions. Flow sheets and checklists are frequently used to record interventions, but there may be no additional documentation to substantiate the patient's/client's responses to the interventions and the subsequent need to revise the plan of care. Too often, the documentation lacks apparent connections between interventions, functional problems, and outcomes. Physical therapists commonly document a discharge summary but may fail to include pertinent discharge criteria about anticipated goals and expected outcomes.
Often, practitioners focus on payment for services as the primary reason for documentation of patient care. Economic factors can influence symptom reporting, as can pending litigation with potentials for monetary rewards. Payment for services may promote unfavorable behavior changes in practitioners, such as misrepresentation of information in the patient/client record to obtain reimbursement from insurance companies. Wynia and colleagues10 surveyed 720 practicing physicians and reported that 39% used falsified patient information or exaggerated symptom severity to obtain insurance authorization. As an explanation for this deceptive documentation, the authors offered the term covert advocacy to describe the behavior that results from the tension between patient advocacy and cost containment,.10
Nadler et al (2004) reviewed documentation of a straight leg raise (SLR) test in 200 people with a diagnosis of lumbar radiculopathy or disc herniation. Documentation of a positive SLR was more likely if patients were covered under personal injury insurance programs than if they were covered under a managed care workers' compensation program. The likelihood of a positive bilateral SLR diagnosis was even more strongly associated with a personal insurance program. The authors concluded that there might be numerous explanations for these differences, including exaggeration of symptoms by participants, covert advocacy, differences in education levels of providers performing the test, and poor technique or improper interpretation.11
Although these studies involved physicians, not physical therapists, it is not too far a leap to imagine that deceptive documentation could occur in physical therapy practices as well. For example, many physical therapists believe that Medicare patients in the acute setting would not be admitted into a rehabilitation setting if the documentation said that they could walk more than 150 feet, so they record that the patient walks 50 feet times 3, an example of covert advocacy. Or they believe that patients would not be considered homebound if they walk more than 100 feet; therefore they may well feel the need to practice covert advocacy and record that a patient can ambulate fewer than 100 feet when this is not true.12 Interestingly, Medicare guidelines focus on the need for skilled care but do not specify number of feet as a decision determinant.
Lack of Standardized Terminology
The lack of standardized terminology across health professions has affected the quality of documentation. Poor documentation leads to uncertainty in interpreting patient information, impairs communication among providers, and decreases the continuity of care. Müller-Staub et al (2007) evaluated the impact of an educational program to improve implementation of standardized nursing diagnoses (NANDA), interventions (NIC), and outcomes (NOC) based on the premise that standardized language would lead to improved data management and enhanced quality assessment of nursing practices in the areas of diagnosis, intervention, and outcomes. Results indicated that standardized language led to an improvement in the formulation of nursing diagnoses, identification of signs/symptoms and correct etiologies, specific nursing interventions, and documentation of nursing-sensitive patient outcomes.13
Oostendorp et al investigated the intrarater and interrater reliability and internal consistency of physical therapy documentation based on a set of quality indicators developed for the study. The authors also looked at the clinical utility of the set of quality indicators and evaluated the quality of physiotherapy patient documentation. They developed a set of 44 indicators, organized into six clusters, representing phases of the physical therapy examination/evaluation process. They are:
General (general patient information)
Three individuals, a physiotherapist/movement specialist, a physiotherapist, and a health researcher, conducted 147 chart reviews from 160 practices in the Netherlands using the set of quality indicators from the six clusters and a scoring system from 0 to 3 (0 = absent; 1 = somewhat present; 2 = mostly present; 3 = always present). After determining internal consistency, intrarater reliability, and interrater reliability, they concluded that the evaluation instrument has apparent clinical utility and that the quality of the documentation was what they termed moderate (mean score 1.6).14
In a pro bono clinical practice setting involving volunteer physical therapists from various facilities and student physical therapists with varying levels of clinical experience and from different academic institutions, the variety of abbreviations is noteworthy. Some examples include:
TB ex (Theraband" exercises)
TAC (transverse abdominal contraction)
DKC (Double knees to chest)
LAD (long axis distraction)
POE (prone on elbows)
Though it is possible to decipher the abbreviations in the context of the patient/client documentation as a whole, it is inconvenient in terms of time and inefficient in terms of communication and data collection.
IMPROVING THE UTILITY OF DOCUMENTATION AS A SOURCE OF EVIDENCE
If documentation is to become a reliable source of evidence, these barriers must be overcome. The recommendations to improve documentation, and thereby improve patient care, have two major themes in common: increasing use of electronic record keeping and improving the links between the documentation and the actual outcomes of care.
Use of Electronic Record-Keeping Systems
Electronic record keeping has been proposed as one solution for improving the quality and consistency of documentation. For example, Knaup et al developed a software system, eardap, that was based on an extensible architecture for using routine data for additional purposes. Just as with clinical research based on a standard terminology, the impetus for the development of this software was the concept that standardized documentation would lead to effective communication through sharing of data based on standardizing terminology.15 Medicare, along with numerous policy organizations and many insurance companies, has supported the move toward submission of electronic records for payment of services on the premise that electronic record keeping could:
Improve the quality of documentation
Increase the efficiency of communication, including that for payment
Improve patient safety and therefore improve patient outcomes16
Despite the promise of electronic record keeping, evidence shows that computer-based systems are not yet the complete answer. A systematic review by Delpierre et al showed that while computer-based systems seem to increase practitioners and patient satisfaction, they were as likely as not to produce positive changes in practitioner behavior related to improved patient care.17 Because of the anticipation that properly implemented computer-based documentation will have great benefits, policy groups continue to try to identify the barriers to full implementation and the means for overcoming those barriers (Box 18.1).18,19
A review of the available literature in physical therapy 20 summarized the benefits (improved reporting, operational efficiency, interdepartmental communication, data accuracy, and access to data for future research) and barriers (need for workflow or behavior modification, software or hardware inadequacy, inadequate staff training) found in previous research about the use of computerized record systems in physical therapy. Based on analysis of the factors that seemed to lead to better success in implementation, the authors of the review recommended that the following principles be used in implementing computer-based systems for physical therapy documentation:
Incorporate workflow analysis into the system design and implementation
Include end users, especially clinicians, in the system development activities
Devote significant resources to training
Plan and test carefully to ensure adequate software and hardware system performance
Pursue the efficient capture of coded data
Commit to data standards
Box 18.1 Principles for Success as defined by the National Research Council in Their Report: Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions Principles for Evolutionary Change
Principles for Radical Change
Focus on improvements in care—technology is secondary.
Seek incremental gain from incremental effort.
Record available data so that today's biomedical knowledge can be used to interpret the data to drive care, process improvement, and research.
Design for human and organizational factors so that social and institutional processes will not pose barriers to appropriately taking advantage of technology.
Support the cognitive functions of all caregivers, including health professionals, patients, and their families.
Architect information and workflow systems to accommodate disruptive change.
Archive data for subsequent re-interpretation, that is, in anticipation of future advances in biomedical knowledge that may change today's interpretation of data and advances in computer science that may provide new ways of extracting meaningful and useful knowledge from existing data stores.
Seek and develop technologies that identify and eliminate ineffective work processes.
Seek and develop technologies that clarify the context of data.
Support for more widespread adoption of computer-based systems has also been expressed in various APTA activities, including adoption of the policy Support of Electronic Health Records in Physical Therapy in 200821 and by support of the Physical Therapy and Society Summit (PASS) in 2009. The Summit focused on a futuristic perspective of health care, including the many opportunities for the use of computer-based systems. One of the major themes of the PASS was also the concept of "disruptive change." Similar to the recommendations from the National Research Council (see Box 18.1), this concept emphasizes the need to be able to recognize and embrace change that makes fundamental differences in current systems.22
Description of Actual Patient Outcomes
If documentation is to provide us with better information about patient care, one of the ways we need to improve is by using more standardized outcome measurements, when such measurement is available. By using standardized tools for measuring outcomes, the data in our documentation can be used in observational studies to describe the results of various diagnostic labels and interventions when used in actual practice, in other words, to help measure the effectiveness of our care.
There are many different kinds of outcomes in which we are interested as physical therapists. We need to measure outcomes across the disability model, starting with any changes to pathology that we might achieve, and then measure changes in function, including body structure, activity level, and participation in behaviors related to role. There are also many other areas where we would be interested in measuring outcome, including patient satisfaction, costs of care, and general, health-related quality of life. A good standardized outcome measure is based on many of the same principles discussed in Chapter 12. Standardized measures must be reliable, valid, and generalizable to the patient population for which we are documenting care. We need to know the ability of the test to measure both clinically meaningful and statistically significant change. All outcome measures should be as objective (free from measurement bias) as possible. Subjective measures are those that are much more susceptible to the bias of the observer.23
One of the most familiar ways to document patient care is known as the SOAP note. Laurence Weed developed the concept for the SOAP note in the 1960s as part of a documentation system. He was one of the first people to make a strong case for the relationship between clinical reasoning and the form of documentation used by practitioners. He proposed that by documenting patient data in an organized way, a person's thinking becomes apparent to others and to him- or herself, it becomes available for careful scrutiny, and thereby both the documentation and the thinking could be improved. His proposal was a fully integrated, problem-oriented patient record system, which included the patient record, regular auditing of the record, and practitioner education based on the audit. The record was to include
An organized database for all information collected about the patient through various tests
A list of the problems that the patient had, extending beyond pathological diagnoses (predating the concept of the disablement model)
An initial plan for care
The progress notes were to be in three forms, the narrative note, flow sheets documenting changes in data over time, and a discharge note. It is the narrative note that has come to be called the SOAP note. Each note was to include:
Subjective notes (what the patient said)
Objective notes (what the practitioner observed)
Assessment of what this meant
Plan for future care
All of Weed's concerns and perspectives are still valid today, but the use of the SOAP note has become somewhat problematic. Labeling what patients report to us as "subjective" and what we observe as "objective" in the note has confused many practitioners about the true meaning of these words. Patients can report information to us that is objective (free from bias), and we can record data we collect that is quite subjective (likely to be biased). We would, perhaps, be better off thinking of the first element as symptoms—what is reported to us by the patient—and the second element as signs—what we observe. A second problem with the SOAP note is that while it has been widely adopted, all the other elements of the record system have not been, thereby significantly reducing the impact of Weed's concepts on improving patient care. But it is easy to see that Weed's ideas form the basis of the clinical decision support systems that are now beginning to be available for practitioners (see Chapter 16).24,25
In choosing an outcome measure, we can ask several questions:
How much system specificity do we need?
A tool containing items that are clearly not relevant to the patient wastes time, but the more specific the measure, the more limited our ability to compare outcomes across large groups.
Does the tool measure the range of outcomes in which we are interested?
Outcome tools have what is termed ceiling and floor effects. This means that some tools are very good at measuring outcomes in people with severe impairments and decreased function and other tools are much better at measuring outcomes in patients who started care with fewer impairments and a high level of function. Very few tools can do both.
Over what time frame are we concerned about changes in performance?
Some tools are best at measuring change across the course of a typical episode of care, such as days or weeks. Others are best at measuring change over long periods, such as months and years, as would be appropriate for patients with long-term or chronic health problems.
Are we interested in measuring changes in one person over time or in comparing the results for groups of patients?
This question is certainly also related to time frame but deals with another fundamental difference. Sometimes we need a tool to help us measure the individual patient's progress toward specific goals, and sometimes we are interested in comparing our overall programs, as in benchmark activities, or in creating databases for evidence based practice or clinical research.
Is the tool completed by observation of patient behavior or by patient report?
It is not possible for a therapist to observe all behaviors, nor is it desirable. For example, we often see a patient after trauma and/or surgery and we need to rely on reports from the patient or family about prior level of function as the baseline outcome measure. Some tools, but not all, have been shown to reliably measure behavior through patient report.
Was the tool really created to measure outcomes across time or did it have another purpose?
Many of the tools used in clinical practice have been developed for a particular purpose. For example, the Berg Balance Score was developed as a screening tool.26 The Functional Impairment Measure (FIM) was developed as a way to compare group data across multiple rehabilitation facilities.27 Neither of these was developed as a means to track outcomes for individual patients across time, although subsequent work has been done to assess their appropriateness as tools for this purpose.28,29 Until the tool has been validated for our intended purpose, it is best to use it for its original, validated purpose.
Can I design a tool that is specific to my practice; can I adapt an existing tool to make it more specific to my practice?
It is tempting, and all too common, to develop "home-grown," idiosyncratic tools for documenting outcomes in patient care. But such tools have not been studied for what is called their psychometric properties. In other words, we don't know their reliability, validity, or generalizability. Therefore, these tools may not be telling us very much at all about real changes in impairment or function based outcomes. And they certainly can't help us in developing databases for evidence based practice.
Just as with other aspects of evidence based practice, the adoption of appropriate standardized measures has been slower than would be desirable. Researchers examining the reasons for this have identified that in addition to the usual barriers, such as perceived lack of time and lack of knowledge, physical therapists also believe the standardized tools do not always provide sufficient description of the quality of movement being observed.30,31,32 Stevens et al have described in a case study the adoption of more standardized outcome measures in one practice, a process very similar to that discussed in Chapter 17. They emphasized that implementation of outcome measures has to be inclusive of documentation strategies but also emphasized that the most important aspect of their plan was incorporating the use into therapists' clinical reasoning.33 Deutcher et al described the benefits of integrating an electronic system with implementation of standardized measures. They concluded that such a system leads to the types of analysis described by Delitto and Bise in Chapter 19.34
New documentation systems for physical therapy have been devised that build on these principles. For example, the American Physical Therapy Association (APTA) has created, in partnership with an outcomes measurement firm, a product known as APTA CONNECT. APTA CONNECT is designed to be a point-of-care, computerized patient record system. In addition to the ability to schedule and register patients, the system contains many standardized outcome tools. The data entered into APTA CONNECT are then loaded into a national outcomes database, which is used to better understand the effect of physical therapy care. In addition, APTA is expanding this national database to allow submission of data from all physical therapists, whether or not they are using APTA CONNECT. (www.apta.org/CONNECT/)
QUALITY IMPROVEMENT SYSTEMS
A full discussion of quality measurement and improvement in health care is beyond the scope of this book. Documentation has been linked to the concept of quality for as long as health-services researchers and clinicians have been discussing quality. Avedis Donabedian is considered one of the founding theorists in this area. He contended that there are three approaches to the evaluation of quality:
Appraisal of structure, including physical structures, qualifications of heath-care personnel, and administrative organization. These structural elements are seen as necessary, but not sufficient to assure quality care.
Appraisal of process, focused primarily on what the health care practitioner does. This approach relies on being able to identify a standard for acceptable, or even best, process.
Appraisal of outcomes, evaluating the end results of care in terms of health and satisfaction. This approach is successful only if all parties can agree on what successful outcomes actually are and is based on a belief, preferably evidence, that the outcomes are actually a result of the care provided.35
This model has been the basis of much of the work done about quality over the past 50 years. Evidence based practice clearly has roots in the model. Figure 18-1 shows the model as well as specific physical therapy examples in each category.
The different Approaches to Measuring Quality.
Donabedian pointed out that patient care documentation is an essential source of information for all three aspects of the model. He documented the prevailing issues of incompleteness, inaccuracy, and potential bias in the patient record, issues with which we continue to grapple today. Considerable efforts have been made at all levels of the health care enterprise (see side bar) to put in place quality assessment techniques designed for all three types of appraisal. Almost all of these techniques rely on good documentation.
Many organizations focus on the issues of quality in health care. Perhaps the two most prominent in the United States are the Agency for Healthcare Research and Quality (AHRQ), which is part of the U.S, Department of Health and Human Services (U.S. DHHS) and the Joint Commission.
As stated at the AHRQ Web site (www.ahrq.gov/), AHRQ's mission is "to improve the quality, safety, efficiency, and effectiveness of health care for all Americans." It further states that the overall focus of AHRQ is on:
"Safety and quality: Reduce the risk of harm by promoting delivery of the best possible health care.
Effectiveness: Improve health care outcomes by encouraging the use of evidence to make informed health care decisions.
Efficiency: Transform research into practice to facilitate wider access to effective health care services and reduce unnecessary costs."
To achieve its goals AHRQ supports research in the following areas:
"Comparative Effectiveness… Comparative effectiveness research improves health care quality by providing patients and physicians with state-of-the-science information on which medical treatments work best for a given condition.
Patient Safety The Patient Safety Portfolio helps identify risks and hazards that lead to medical errors and finds ways to prevent patient injury associated with delivery of health care….
Health Information Technology Through this research Portfolio, AHRQ and its partners identify challenges to health IT adoption and use, solutions and best practices for making health IT work, and tools that will help hospitals and clinicians successfully incorporate new information technology….
Prevention/Care Management The Prevention/Care Management Portfolio focuses on translating evidence based knowledge into current recommendations for clinical preventive services that are implemented as part of routine clinical practice to improve the health of all Americans….
Value Research The Value Research Portfolio aims to find a way to achieve greater value in health care—reducing unnecessary costs and waste while maintaining or improving quality—by producing the measures, data, tools, evidence and strategies that health care organizations, systems, insurers, purchasers, and policymakers need to improve the value and affordability of health care…."
In its role as an arm of the federal government, AHRQ makes its findings and those of the researchers it supports freely available through its Web site, which has material designed specifically for consumers and for practitioners. It is well worth a regular review; viewers can also request that material be forwarded to them via e-mail.
The Joint Commission, as it reports at its Web site, www.jointcommission.org/, began as a concept of Dr. Ernest Codman, an orthopedic surgeon who is widely considered to be the first major spokesman for health care quality. In 1910, he proposed that hospitals should begin tracking the end results of the care provided to patients, and when the results were not satisfactory, the hospital should endeavor to determine why and make necessary changes to improve. (Physical therapists may be familiar with Dr. Codman's name, as it is attached to a group of post-operative shoulder exercises long used in physical therapy.) Work by various physicians and hospital groups on this concept led to the formation of the Joint Commission on Accreditation of Hospitals (JCAH) in 1951, with the purpose of giving accreditation to hospitals that met certain minimum standards. Through the years, the Joint Commission's role has expanded to include many other types of health care organizations so that its current mission is stated, "All people always experience the safest, highest quality, best-value health care across all settings."
The earliest efforts of the Joint Commission focused on appraisal of structure; it subsequently has taken many initiatives related to quality assessment and improvement. This increased focus on the appraisal of process has relied on documentation to determine quality. In the 1970s, the Commission began promoting the use of the chart audit to identify if a predetermined set of activities had occurred with particular patients. Most recently it has implemented a new program stressing the use of measures for quality improvement that meet these four criteria:
There is a strong evidence base showing that the care process leads to improved outcomes.
The measure accurately captures whether the evidence based care process has, in fact, been provided.
The measure addresses a process that has few intervening care processes that must occur before the improved outcome is realized.
Implementing the measure has little or no chance of inducing unintended adverse consequences.36
Once again, the close interaction between evidence based practice, quality improvement activities, and documentation has been demonstrated. These two agencies, one a federal initiative and the other a voluntary initiative on the part of health care providers, lead the way in policy making in these areas.
Studies of implementing various means of improving documentation generally show some benefit. For example, Gumery et al (2000) reported the effect of chart audits done pre- and post-training on improving physical therapy documentation for patients in an adult cystic fibrosis unit in Birmingham, England. The purpose of the study was to assess adherence to professional standards of the Chartered Society of Physiotherapy (CSP) and the Association of Chartered Physiotherapists in Respiratory Care (ACPRC) by all physiotherapists working in the adult cystic fibrosis unit. The authors concluded that chart audits and training were useful tools in improving documentation and can lead to five key outcomes:
increased knowledge and understanding of effective practice,
increased effectiveness of service provision,
improved quality of patient care, and
demonstration of commitment to evidence-based practice.37
Efforts to use documentation as a means of improving the quality of health care have been under way for at least a century, yet documentation still does not always achieve the quality required for it to be readily used as an accurate record of care, as a basis for developing evidence from practice, and as a mechanism for measuring and improving quality. What can we do to change this situation? We appear to be at the point where electronic systems can provide all of the elements needed to make documentation a successful tool for quality assessment and improvement, including ease of use, access at the point of care, and ability to document the complexity of patient care. Zhou et al38 bring us full circle with their work showing that simply implementing electronic systems is not sufficient. Success is linked to the system's ability to help the practitioner make better decisions. Chapter 19 describes just such a program in actual physical therapy practice. Other examples will be available at the F.A. Davis Web site for this text. We can also recognize the issues discussed in Chapter 17 to help reduce barriers to successful implementation. Perhaps the growth of point-of-care decision-support systems, as discussed in Chapter 16, offer the best possibility for the future.
Review the documentation provided about Mr. Ketterman in the Appendix. Although it contains more than would typically be found in a clinical chart, review those elements that would be contained in a patient chart. What suggestions can you make to improve this documentation? What can you learn from the example to improve your own documentation?
Review three or four clinical charts. Do they meet the standards identified in this chapter? What suggestions would you make to the clinicians who documented in the charts to improve the record?
Identify the documentation system used in your clinical practice or in one with which you are familiar. Is there a system that you can identify? Does the system have the right elements to support good physical therapy documentation?
The APTA has developed Defensible Documentation as a tool to help clinicians improve their documentation skills. Downloadable documents are available to members only at www.apta.org/Documentation/DefensibleDocumentation/, and an Internet-based course is available to all at learningcenter.apta.org/. Either of these tools has a great deal of information that can be helpful in improving documentation in a wide variety of settings.
Identify the outcome measures used in your practice. Identify what is known about the reliability, validity, and generalizability of these measures for your given patient population. The book, Is Change Real? by Riddle and Stratford (Philadelphia, FA Davis, 2013) can be useful in determining whether you should adopt or change outcome measures in practice.
Review the quality-assurance activities in your practice. Determine whether they measure the quality of the structure, process, or outcome of care. Do you have ideas on how to improve these activities?
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