Keep Your Documentation Clear
Something new happened to me a few days ago. A patient I had discharged from therapy the day before was back on caseload. I wasn't too surprised because that does happen. I got a real surprise when I read the documentation. I had written a long, detailed note explaining that the patient did not want therapy. She refused to participate with an evaluation and clearly stated she did not want therapy. I took her off caseload but requested a re-consult if she changed her mind. I also discussed the situation with nursing which I included in my note.
That sounds pretty simple and straight forward to me. It must not have to the therapist that followed me. The second note was written 90minutes after I left the patient. It stated the patient was now agreeable to therapy. It also contradicted everything I had written earlier. It made my reasons sound invalid and I was wrong to have discharged the patient because of them. There was no indication that a physician or other health care professional was involved. Although, there is a progress note from her physician written between the two visits, so perhaps the physician said something to the patient.
The physician may have also said something to the second therapist. For some reason she went back and reassessed the patient. I don't know what happened because her note doesn't offer an explanation. Except for the order I responded to there were no therapy orders. I don't know because she has yet to tell me what happened. If I go back and change someone's plan of care I always let the other therapist know what happened and why. I write my notes to reflect what changes have occurred. I describe the new plan of care and treatment. I don't comment on previous notes or rationale.
I've never known a PT to be discourteous to another PT. I've never seen anyone contradict someone else in a chart. I've seen doctors go back and forth in their notes. They might disagree but they are never disrespectful of each other. If a doctor takes over because someone else made a mistake you don't know it from the chart. The treatment plan changes based on new clinical reasoning and new orders are written. I wonder what the second therapist was thinking and why she hasn't told me what happened. If I made a mistake I would like to know so I can prevent it in the future.
All I can think of is she didn't realize what she wrote could be interpreted in different ways. For some reason she may have felt an explanation was needed. In that case all she had to do was indicate the physician requested a second evaluation. Details of why weren't necessary. Maybe she thought she was putting out a fire instead of creating one. If the situation were reversed she would have been angry with me. Maybe because I am a contract therapist she felt something extra was required. It doesn't really matter. She had a reason. The problem is she didn't feel it was important to tell me, only to say I was wrong. I'm giving her the benefit of doubt. I don't think she deliberately meant to say what she did.
I'm going to find her tomorrow no matter what. If I have to sit outside a patient's room and wait for her, I will. I deserve an explanation. Documentation needs to be accurate and concise. I've been told to document what I did and what happened. The rest is unnecessary. That's good to remember because it is easy to get bogged down in details. This is probably a misunderstanding that was poorly documented. I thought my note was thorough but maybe I was wrong. She could have thought her note was clear but it wasn't. We'll straighten it out. And maybe both of us will remember to be clear with what we say when we write our notes.