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PTA Blog Talk

Reading My Documentation

Published December 23, 2008 3:43 PM by Jason Marketti
Before computors I wrote all my notes out in long hand and could scrible the "n's" and "m's" or add a dot above the word if I wasnt sure the word had and i or an e.

There was no spell check with red underlnes or grren wavy lines if the sentances didn't make sence.  Oh the good old days when mis-spelings were not noticed as easily.

We are getting a new computor at my work.  It will contain all the billing, documentation and time in/out for us.  The documntation scares me.  I am not the best speller nor am I the most eloquant when it comes to therapy phrases to denote progress.  I hope it will have spelll check on it, although some of the medical words we use come up as wrong. 

And what do I do if I see another co-worker continueously mispell a word?  Should I subtley buy a dictionary or pretend the word is correct?  And what will happen if a not needs to be sent to the doctor?  Do I write it or let the worst spellar do it and really make our department shine?

Some places will use a simple check the box method for progresses notes with limited room for actual writting.  This is good but may lack the full extent of a pateints progress.  And if we write too much it may set us up for a denial or a lawsuit. 

I have also seen too little documentation where I had no clue what the patient did or how they had progressed.  Is there a happy medium with documenttion?

P.S. how many mistakes were in this post?

2 comments

On a cursory pass I caught 20 (speling puctuation and Capitalization), unless you include the ps, then 21 :-)

Cute post...creative way to make your point.

Janey Goude January 10, 2009 4:11 PM

15?  

I am not the best speller either.  Maybe this should be a test for us during our schooling.  I have seen horrible spelling by MD's, NSG, and PT/PTA's.  

A remedial english course works wonders in health care.

Karen December 27, 2008 10:53 AM

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About this Blog


    Jason J. Marketti
    Occupation: Physical Therapist Assistant
    Setting: San Jacinto, CA
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