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This section will guide clinicians through a pilot study of their own documentation patterns.

This is a reasonable starting point for the clinician who would like to begin tracking outcomes in a practice setting. A study of documentation patterns will reveal whether patient characteristics or measures are recorded consistently. Inconsistent documentation will need to be addressed to establish a source of usable data before other clinical outcomes can be studied.

The steps of this study follow the explanations provided in Part 2, Chapters 712:

  1. Identify an interest, and form the question (Chapter 7)

  2. Conduct a search of the literature (Chapter 8)

  3. Identify a rationale for conducting the study and potential action plans (Chapter 8)

  4. Define relevant variable codes (Chapter 9)

  5. Create a data set (Chapter 10)

  6. Analyze the data (Chapter 11)

  7. Interpret results, and create a report (Chapter 12)

You will be recording the disablement category of each goal and the measurability of each goal for the purpose of personal self-improvement in documentation practices. Other characteristics of documentation can be measured as well, but for a first study, it may be useful to limit data harvesting to the initial evaluation. For clinicians with more experience, consider whether a final measurement needs to be recorded for each goal set.

The study is limited to those records that were personally completed by the clinician conducting the study to accommodate HIPAA regulations. Be aware that for review of any records other than your own forms, or if the study results will be presented or published in any public venue, institutional review board (IRB) approval should be obtained prior to data harvesting.

Step 1: Identify an Outcome, and Form the Question (Chapter 7)

In this pilot study, the following PICO question can be used to examine the types and measurability of patient goals.

What are the distribution and measurability of impairment, functional limitation, and social goals in the initial visit documentation for patients with [insert a diagnosis of interest] in this [identify type of health-care facility] setting treated by this therapist?

  • P For patients with (a particular diagnosis), treated in this (specify type) facility, by this therapist

  • I who have impairment

  • C functional

  • C social goals

  • O What is the frequency of goals in each disablement category?

  • O What is the frequency of measurable goals in each category?

Remember to pick a diagnosis that is common to your practice or one that presents particular challenges. Licensed clinicians should review the records of patients who were managed personally, including the write-up of the initial evaluation. Nonlicensed clinicians, or those who do not have access to patient records, may use the data set provided in Appendix 3...

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