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Raising the Bar in Rehab

Legal and Ethical Documentation

Published October 11, 2012 4:24 PM by Lisa Mueller

I'm about halfway through with reading a book for work called Legal, Ethical and Practical Aspects of Patient Care Documentation: A Guide for Rehabilitation Professionals by Ronald W. Scott.* At my previous job I was the chair of the documentation committee, and as a writer for this blog and other pieces I'm interested in maintaining a high standard for a patient's written record of care. I started reading this book as a way to research and improve our chart review process at work and to educate myself with documentation specifically from a rehab standpoint.

The author is not only a physical therapist, but also an attorney holding six academic degrees, per the introduction of the book. As I started reading through the first few pages (with highlighter in hand), I was surprised how prevalent the themes of liability and malpractice were discussed. My documentation training in school and clinicals was focused on details regarding the patient's status, so I did not often think of a chart in terms of legal evidence. But a patient's chart is certainly a legal record of care and the author carefully outlines recommendations to ensure the highest quality and accuracy of documentation.

The more of the book I read, the more I think about my fellow blogger Toni and her experience working temporarily at a facility only to find that several patients had no written documentation on file. I encourage you to read her experience and lack of support from the management of that clinic.

Before I read this book I thought my documentation was good, even great at times. I am very detailed and timely. I use professional vocabulary. The pages of my book are now covered in yellow highlighter and little pen marks pointing me to areas where I need to improve. There's a lot I could be writing better.

The author does many things well in writing this book. First, he ties documentation back to quality patient care many times. Educating our patients and getting consent for treatment alone could prevent many legal cases against therapists, and those are two areas where therapists should prevail. Secondly, the book is not focused on reimbursement. I like this, because I like the philosophy that physical therapy is not about money -- it's about providing care to help our patients.

Eventually I'm going to take parts of this book along with the APTA's defensible documentation notes and create a thorough chart review process for our rehab team. There is a lot to include and making minimum standards will be somewhat difficult, but better documentation will only improve our communication with other providers and therefore result in better care for our patients.

Tell me about your clinic. Do you participate in chart reviews? Do you think you understand the legal aspect of documentation, or would you be interested in learning more? What are the standards of documentation at your clinic?

* Dr. Scott has also co-written several articles for ADVANCE. The most recent one covered "Lowering Liability Risks for PTs."


The communication aspect of treatment I find to be extremely important in terms of liability issues. Yes, consent is obviously important, but did the patient understand what you told them? How do you know? They may have understood, but did they agree with it? When beginning a new case I will often write that the plan of care, visit frequency, and expected outcomes were discussed and "the patient voiced understanding and agreement with all". As treatment becomes more distinctly "person centred" these types of observations and notes will play a greater role in our documentation. The NHS has just enacted guidelines that specify clarification of both understanding and agreement with interventions.

Dean Metz October 14, 2012 4:49 PM

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