Documentation

To Write or Not to Write

That Is The Question!

Program Objectives

Upon completion of this program, the participant will be able to:

• Describe the importance and key points of documentation.

• Complete an Assessment.• Discuss the components of a progress and

discharge note.• Increase knowledge of appropriate

documentation.

Case Manager’s Documentation

When is enough enough and when is too much?

It is important to be clear and concise. NASW states:

" Organized documentation reflects the hallmark of quality social work and serves as a mode of communication between a social worker and other professionals.”

NASW Standards for Social Work Practice in Healthcare Settings 2005

Documentation is the key to everything. In the eyes of the law, if it is not documented, it was never

done!

3 Key Points in Documentation

• The Assessment should be thorough, to the point, and include history of the patient, current needs, and recommendations.

• The Progress notes should tell what interventions and specific interactions have occurred.

• The Discharge note should tell the final plan/end of the story. Where the patient went and what services were arranged.

The Assessment is a Snapshot

• Age• Sex• Marital status• Advanced directives• Language needs & cultural considerations.

The Assessment is a Snapshot

• Admitting Diagnosis and history of illnesses.• Current Living situation.• Preadmission and current functional status. • Support systems & psychosocial evaluation.• Identify projected needs.• Provide recommendations.

Assessment Tool

(Insert individual hospital assessment tool)

Assessment – Example

Consult received. Patient referred to Success Rehabilitation Center.

SNAPSHOT: Is this helpful? What do we really know about this patient?

Assessment Example

Consult received from physician. Chart reviewed and spoke with patient. Patient is a 76 year old, alert and oriented, married female. Resides with husband in a one story single home. Adult daughter lives in area and visits 2 -3 times a week. Prior to hospital admission Patient was independent with ambulation and ADL’s. She drove auto to appointments and shopping.

SNAPSHOT: Is this helpful? What information are we missing about this patient?

Assessment Example

Consult received. Chart reviewed and spoke with patient’s daughter. Patient is a 94-year old, widowed, female. Admitted on 6/28/2007 from Gray Village Nursing Home, with diagnosis of failure to thrive. Past medical history includes hypertension, Type II diabetes ,and UTIs. Patient is confused and hard of hearing. Prior to admission patient was total care.

Assessment Example (Cont’d)

Patient will continue to need placement post discharge. Daughter wants patient to return to nursing home upon discharge. Called nursing home admissions and patient is a bed hold. Will continue to follow and assist with return to nursing home when stable.

Assessment Example (Cont’d)

SNAPSHOT: Is this helpful? We now have a complete picture of this patient and a tentative plan of care.

Progress NotesDocumentation Flow

Tell the story: Who, What, When, Where, Why and How!

• Interventions.• Options provided. • Specific interactions.• Patient and/or family agreement to plans.• Services arranged and cost explained.• Resources & Education provided.• Update recommendations and next steps.

Discharge Note

• Final plan• Destination – Level of care• Confirmation of discharge

• Patient and family• Staff• Community providers

THE DOs and DON’Ts

Do’s:• Date and time• Signature• Be factual• Include observations• Identify your hospital’s documentation format.

• Narrative• SOAP• SBAR

DO’s and DON’Ts

Don’ts:

No negative documentation.

Do not be judgmental.

Do not generalize.

Don’t forget to sign and date notes!!!!

Summary of Key Points

• Paint the picture.• Be concise, to the point. Consider bullet

point statements.• Update progress notes per hospital policy.• Be specific with your discharge note

documentation to include final disposition as it affects coding and billing.

Review

• Group Case exercises.• Written question/open group review.

Group I

What is wrong with this assessment?

GROUP I

Mrs. Curry is a 78 year old female. Physician ordered discharge to Peace Rehabilitation and Nursing Center. Referral made and patient scheduled for discharge at 13:30 via Merry Van Transport. Patient will be billed for transport services. Mary Weathers, MSW

GROUP II

Write an assessment of this patient

GROUP II

Write assessment on the following patient:

• Emma Carr• 9603 Raceway Road, Apartment 1A, Hot Wheels,

Florida, • Telephone 727-555-1212• DOB: 01/01/1923• Contact: Robert Carr, husband @ 727-555-1212• Prior to admission: Patient used a cane. Drove

auto.

GROUP III

Identify errors in the document.

GROUP IIIJuly 22, 2007: Patient is a 72 year old, widowed female. Alert and oriented times 3. Lives alone in a one story single home. Prior to admission, patient was independent with ambulation & ADLs. Drove auto. Physician ordered DC plans to Happy Land Rehabilitation Center. Patient provided list of area rehabilitation centers. Referral to Happy Land Rehabilitation center made. Mary Willrite, BSW

July 29, 2007: Patient discharged to HipHop Rehabilitation Center. Mary Willrite, BSW

Review Questions

1. What are the three major parts of documentation flow?

2. Assessments should be :a. Brief and to the pointb. A snapshotc. Tell what is neededd. All

3. Progress notes provide what information?

Answer Key

1. The Assessment, the Progress Note, and the Discharge Note

2. B-Snapshot3. Progress notes provide:

• Interventions• Options provided • Specific interactions• Patient and/or family agreement to plans.• Services arranged and cost explained.• Resources & Education provided.• Update recommendations and next steps.