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PTA Blog Talk

Get it in Writing

Published September 22, 2009 9:51 PM by Jason Marketti

As a PTA I have to rely on the PT for accurate and up to date information in order for me to perform my duties.

I have been to places where all the notes were up to date with the latest tests and accurate documentation and if one piece of information was missing the provider responsible for that patient got a talking to.  I have been to other places where I had a hard time finding the evaluations in the charts and progress notes were scarce due to the high turn over rate in patients and staff.

I have had PT's tell me verbally what they would like to do with the patients but then in the written POC it was different and my note appeared to be way off base as to what the PT decided to do once all the paperwork was completed.   My general policy is to completely trust the PT when they verbally tell me to do something with the patient. 

I may change that policy however.  As I do more research on documentation it is better to have everything written down so there is no confusion as to what should be done with the patient and both the PT and PTA are protected as to what activity the patient is able to participate in.  The PTA can carefully review the POC and goals and ask questions about them for clarification and if there are any contraindications they can ask the PT about it. 

The big concern is for the PTA.  What if in the middle of treatment someone from the state board would like to see the evaluation and plan of care of the patient to ensure compliance.  We technically should not be allowed to treat a patient until we have an evaluation, however I would check with the licensing board, but I am sure they would not want us to treat patients until a evaluation is completed and in the chart. 

Let me know, should PTA's treat a patient before the evaluation is written?

 

3 comments

Jason, There is a reason that JCAHO insists on read back of verbal orders and then documenting VORB next to it in the chart. They acknowledge that one of the primary areas for medical errors is in the verbal order process. Let us assume that the PT simply forgets a particular task he/she instructed you to perform. That leaves you exposed.

Do you document your coordination with the PT? That can act as a reminder for the PT when they go back to document the instructions they gave to you. The safest route for you though is to respectfully decline to begin a new treatment until the paperwork is completed. That is what I would do.

Dean Metz, Physiotherapist September 23, 2009 10:17 AM
Newcastle Upon Tyne

I have been in these positions, and from experience, will never touch a patient again unless the paperwork is complete. Cover yourself first!

If the PT isn't up on the paperwork and it lingers, it could come back to bite you as well as the PT. To the point of fines or loss of your liscense. My policy is to error on the side of caution. If my PT doesn't complete paperwork, then he/she will have to treat that patient until its done. Once that paperwork is up to date, I'll treat as long as I have an active plan of care and goals that can be reached.

Any PT/PTA should have enough mutual respect not to put the other in a position that could professionally destroy the other.

Again, from past experience, I'll never treat a patient until that paperwork is complete!!!! My advise is to make it your policy too.

Medicare and your state board will side with you if your company demands that you treat without a written plan of care. Just ask, I did.

Carla, PTA September 23, 2009 9:54 AM
KY

It depends on the relationship the PT and PTA have.  It takes faith to completely trust the PT but since both PT's and PTA's have a license both should take responsible care in protecting themselves.  If in doubt about whether you should see a patient or not, wait for the paperwork.

Karen September 23, 2009 9:18 AM

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