Documentation & Communication in Adult/Medical Settings. Devina Acharya, MA, CCC/SLP, CSUSM
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1 Documentation & Communication in Adult/Medical Settings Devina Acharya, MA, CCC/SLP, CSUSM
2 When in Rome. do as your facility does 2
3 Who s the Boss? Doctor makes decisions and bears ultimate responsibility for the patient 3
4 Continuum of Care Acute/ Inpatient ICU IMC/ Tele Med- Surg Rehab ARU SNF Home Health Outpatient Clinic Day Tx Group Program 4
5 Medical Charts Physician s Orders History & Physical Nursing Notes Ancillary Notes Recent Results 5
6 Physician s Orders Verbal Telephone Written Always check the chart & speak to the nurse first! Read back 6
7 H&P Chief complaint History of present illness Past medical/ surgical history Review of systems Social/ family history Medications Allergies Physical examination Labs/ studies Assessment Plan 7
8 Nursing Notes Vital signs, input/output Medications Communication Narrative Tests and procedures 8
9 Ancillary Notes Physical Therapy Occupational Therapy Speech Therapy Respiratory Therapy Dietary Social Work Other Doctors write in MD Progress Notes 9
10 Recent Results Objective data Radiology Lab tests 10
11 Funding Self-pay HMO/ PPO MediCal Medicare Authorization? 11 Third-party payors
12 Funding Issues in Rehab Acute Rehab Skilled Nursing Facility 3 hours of tx daily Consistent progress Home discharge Identified caregiver 100 days covered Skilled need Show progress May become custodial 12
13 Rehab Documentation Evaluation Discharge notes Orders Progress summaries Daily notes 13
14 Evaluations Identifying info & history Objective/subjective data & diagnosis Long-term/short-term goals & client s goal Treatment plan & prognosis 14
15 History Diagnosis, if known Prior medical history Age, gender, presenting complaint Paint a picture Prior level of function 15
16 Prior medical history Cardiac Neurological Respiratory Add recent relevant info Decide what s pertinent 16
17 Example of History 83 y/o M admitted with L-sided weakness, confusion, gait disturbance. Dx: R temporal/parietal CVA. PMH: L CVA 2009 with residual aphasia, R hemiparesis, DM, HTN, CABG PLF: Home with wife, caregiver 4 hrs/day. Regular diet, uses walker. 17
18 Objective/Subjective Data Mental status, participation Performance of all areas tested Standardized test results Type and level of cueing required Client s response to strategies 18
19 Mental Status Alert Agitated Cooperative Lethargic Combative Use any combination to describe the client Disoriented Restless Confused Oriented x1-4 Minimally responsive 19
20 Performance in various areas Auditory comprehension: Pt responds to 2-step commands and egocentric/ concrete Y/N Qs. Breaks down with increased length/complexity. Object ID by name and function in f:2 90%. Verbal expression: Pt communicates at phrase-level with frequent groping and phonemic paraphasias. Names objects and family members with phonemic cues and phrase-completion. Automatics 80%. Reduced awareness of errors. 20
21 21 Performance in various areas Reading/writing: Reading aloud at phraselevel yields greater fluency; however, comprehension is poor. Unable to match words to pictures. Writing could not be tested due to weakness of dominant R UE. Speech production: Approx 75% intelligible at phrase-level due to imprecise articulation, reduced breath support. Responds well to cues to overarticulate and reduce rate.
22 Performance in various areas Cognition: Testing limited by communication deficits. Oriented to self/place, able to ID family members by name and relationship. Unaware of flaccid R UE. R neglect evident. 22 Summary: Pt presents with mild receptive and moderate expressive aphasia with apraxia. Underlying cognitive deficits include R visual neglect and poor awareness of deficits.
23 Evaluations Identifying info & history Objective/subjective data & diagnosis Long-term/short-term goals & client s goal Treatment plan & prognosis 23
24 Long-term vs. Short-term Short-term goals in different areas Short-term goals in different areas Short-term goals in different areas One long-term goal for communication/cognition 24
25 Time-specified (roughly) Long-term 2 weeks in acute 1 month in rehab 3 months in outpatient Short-term/ objectives 1 week in acute 1 week in rehab 1 month in outpatient 25
26 Goals WHO will DO what under what CONDITION meeting what CRITERIA 26
27 Goals Client/ caregiver will perform a behavior with specified assistance or particular circumstances with determined outcome 27
28 Goals Client/ caregivercentered Functional Conditional Measurable 28
29 SMART Goals S M A R T Specific Measurable Attainable Relevant Timely 29
30 Feasible Long-term Goals Consider client s current level Consider client s potential Consider client s motivation 30
31 Long-Term Goals: Examples Client will communicate/comprehend at basic needs level with mod cues in 4 weeks. Client will demonstrate appropriate communication/cognition for safe home discharge with 24-hour supervision in 4 weeks. Client will communicate independently at community-level in 2 weeks. 31
32 Selecting Short-Term Goals Try to address all significant areas (e.g., receptive, expressive, speech, cognition) What will make most impact on client s communication right now? What is most important to the client? 32
33 Client/caregiver-centered Client will Staff will Spouse will... Not Therapist will 33
34 Functional follow 3-step commands produce words be oriented x4 provide biog/family info recall 5- sentence paragraph 34
35 Conditional with min/mod/max assistance given auditory/tactile cues with written prompt in distracting environment... after 20 minutes 35
36 Measurable with 80% accuracy. in 6/10 trials. x10 in 30- min session. with 75% intelligibly. in 4/6 sessions. 36
37 Tips on Goals/Objectives 37
38 Evaluations Identifying info & history Objective/subjective data & diagnosis Long-term/short-term goals & client s goal Treatment plan & prognosis 38
39 Treatment Plan Type of tx Duration Frequency 39
40 Treatment Plan Examples Individual dysphagia tx, 5x/week x 2 weeks Group speech/language/cognitive tx, 3x/week x 4 weeks Individual voice tx 2x/week x 8 weeks 40
41 Prognosis Potential for achieving goals and/or returning to PLF Good, fair, guarded Therapy must be justifiable If fair/guarded, why are you treating them? 41
42 Rehab Documentation Evaluation Discharge notes Orders Progress summaries Daily notes 42
43 Orders Calling doctors Writing summaries Orders/ referrals Treatment clarification 43
44 Know Your Place Know your scope of practice Consult your colleagues Make recommendations with respect Teamwork: it s all about the client 44
45 Rehab Documentation Evaluation Discharge notes Orders Progress summaries Daily notes 45
46 Daily Notes Objective data Show progress towards shortterm objectives Narrative notes 46
47 SOAP Notes S: O: A: P: Subjective: How the client seemed, what the client said. Pt alert, cooperative; wife reports increased phone use. Objective: Results of treatment activities. 2-step commands +4/5. 70% intelligible in conversation. Assessment: Analysis of performance, progress. Use of strategies increased from 50 to 75% in sentences. Plan: Where we go from here. Target carryover of strategies into conversation. 47
48 Charting Towards Goals Address all short-term objectives Goal #3 not targeted as focus was on verbal output. Comment on tasks in context of goals If goal is mod assist or 60% accuracy, provide today s assist level or percentage. 48
49 Always Include Facility policy re. date/time Client input Write legibly! Education provided Name/signature with credentials 49
50 The Stereotype is True 50
51 Rehab Documentation Evaluation Discharge notes Orders Progress summaries Daily notes 51
52 Progress Summaries Acute: Rarely done due to short length of stay Rehab: Weekly Outpatient: Monthly 52
53 Rationale for Continued Therapy Making progress so benefiting from tx BUT has potential for further progress 53
54 If therapy is continuing: Proceed towards longterm goal Update plan with new objectives 54
55 Decline in Status Explain reasons for not achieving goals Adjust goals or continue same goals as indicated Significant change in status may warrant re-eval 55
56 Discharge Notes Summary of progress Next level of care Current status 56
57 Verbal Communication Doctor Staff Family Patient 57
58 Above all 58
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