I work in an out-patient setting at a University based hospital. A good
deal of time is spent on documentation .There are many regulating agencies,
each demanding their own particular vernacular. JCAHO wants weekly
assessments, patient's personally chosen goals, progress towards goals.
Medicare wants us to document exactly how many minutes we spent on
mobilization, vs. how many minutes of gait training , or therapeutic
exercise, etc. All insurances demand daily notes. Many insurances require
a plan of care before they will authorize treatment.
It is unfortunate that we have to spend significant time playing the game
by their rules in order to get paid. Obviously, good documentation
provides better treatment for our patients, however, I think some of the
above agencies border on obsessive.
Janice Michaels, PT, MS
Dept. of PM&R
University Hospital
Syracuse, NY
>>> "Neumann Isaac Rutger, Granheim"
<[log in to unmask]> 05/18 7:12 AM >>>
I'm a bit curious about how much PTs (have to) document their treatment.
I Belgium where I did my education, documentation was hopeless. As a
student
I treated patients in my pratice periods, but hardly ever did I have to
write things down (legally speaking very strange and dangerous). Later in
Holland ('97) the laws were not that strict either (I think it has changed
there now). In Sweden things were much better: in the hospital where I
worked we had write down "everything". Currently here in Norway I can say
that the system is quite responsible and we write down pretty much
everything we do.
How is this with you?
Isaac
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