HCM387-0802A-01 Management Principles in Health Care - Phase 2 Discussion Board - Essay Example

Health professionals often cite documentation as their least favorite job responsibility. Often it is considered a “waste of time” or meaningless paperwork. However, it serves several legal and ethical functions. Moreover, if documentation is done properly, it can be a valuable tool for increasing interdisciplinary communication and therapeutic effectiveness as well as provide a vehicle for patient and professional advocacy. The purpose of documentation and management of patient information are: to provide a chronological record of the consumer’s condition, which details the complete course of therapeutic intervention, facilitate communication among professionals who contribute to consumer’s care, to provide an objective basis to determine the appropriateness, effectiveness, and necessity of therapeutic intervention reflect the practitioner’s reasoning.

There is a tremendous variation in the forms and amount of documentation found in different health professions. However, a recommended procedure includes an evaluation summary, a treatment plan, progress notes, and a discharge summary. This is typically, but not uniformly required for reimbursement and/or institution accreditation. Aside from this, technology has provided the healthcare facilities faster, easier and more efficient way of handling patient information which would help in documentation of data.

There are different software or programs developed by hospitals to cater to this growing need for automation in almost every process of record keeping. Often, health care facilities have their own evaluation forms with information relevant to the treatment provided in the particular setting. In these cases, the summary is usually provided in a short narrative at the end of the form. The evaluation summary is crucial because it provides the baseline data by which the success or failure of treatment is measured.

Some treatment plans are written in the form of behavioral objectives, others are simply an added dote to the evaluation form or first progress note. In some settings the actual treatment plan is only written on a form for reimbursement purposes. For example, Medicare requires a form known as a Plant of Treatment (POT). Regardless of format, all treatment plans should contain goals that realistically can be obtained the particular setting and typical treatment time frame and should clearly represent the domain of occupational therapy.

If treatment should last a couple of sessions, goals should be broken down into short and long term. Progress notes may be required, at least for reimbursement purposes, to chart a note following every treatment. Institutional protocol generally dictates the type of notes expected. Regardless of the type, it is expected that the professional service rendered will be stated and that an assessment of the individual’s progress toward established goals will be noted. The purpose of discharge summary is to assess the overall treatment process by stating the intervention provided, the goals met and not met (and rationale), and recommendations.

Discharge summaries are, all too often, a single line at the end of the last treatment note. This is unfortunate because if the patient goes on to receive other treatment, as well-written discharge summary can be invaluable to the new treatment team. Mechanisms should be established in every health care setting to facilitate the continuity of a patient’s care by providing appropriate information. For example, it is not uncommon for a patient to transfer from an acute care hospital to a long-term facility or a day treatment center.

If discharge summaries were provided at each stage of intervention, treatment could be more time efficient. Discharge summaries are often the only contact the occupational therapist may have with other professionals. Therefore, summary can be a powerful tool for promoting occupational therapy services as well as providing input into a patient’s long term care. Skill in documentation comes primarily from practice but even an experience therapist can fall into bad habits. A consistent critique of documentation is necessary to insure quality.

Furthermore, reviewing documentation (one’s own and others) is a valuable learning tool for improving documentation skills. REFERENCES: Berlinger, Nancy, “Ethical Considerations in Policy Development”, Patient Safety and Quality Healthcare, 1 (2) October-December 2004, p.22-4. Lamb, Rae M., et al., “Hospital Disclosure Practices: Results of a National Survey”, Health Affairs, 22 (2) March/April 2003, p.73-83. Popp, Pamela L., “How To—And Not To—Disclose Medical Errors to Patients”, Managed Care, 11 (10) October 2002, p.52-3.