Documentation is extremely important regarding patient care and services delivered. We should be able to justify our services in writing based on the plan of care established. When a patient has a complaint regarding pain, a new injury, or other symptom, writing "nursing notified" in a hospital or SNF setting may not absolve us from complete patient care responsibility.
If notes are reviewed, a question may arise regarding what the therapy department has done to address this, and specifically, the evaluating or supervising PT's reaction to the new symptom the patient has experienced. If the patient's reported symptoms are documented, were they addressed in a care plan meeting or discussed prior to a discharge from the hospital? And what is the end result after the meeting regarding the health of the patient?
Perhaps we did document and discuss an issue regarding a change in status of the patient with the nurse on the floor but that nurse didn't document the conversation in her notes or contact the physician regarding the patient. Now, which health discipline do you think will be believed when the chart is reviewed during litigation?
I've seen nursing notes indicate a patient has "no c/o pain," but during therapy the patient rates pain at 8/10. I'm sure when the nurse documented this the patient was supine, not moving, and had previously been medicated. As soon as the patient begins to move, the pain starts and that's where our documentation should clarify a patient's pain in relation to activity level to alleviate this discrepancy.
The same can be true when a nurse approaches us about a patient's pain level or movement anomaly. If she documents that she has discussed the issue with the therapist but we don't address the issue in our notes, we could find ourselves opposite a Perry Mason-type lawyer who will ask the appropriate questions regarding a therapist's responsibility while caring for a patient.