Documentation should reflect effort to provide a safe environment and protect the patient from harm, gather facts about the patient’s condition, follow-up on diagnostic tests, and provide the patient with information to facilitate self-care/patient engagement in care. We’ve compiled a list of some the most important aspects of documentation for Occupational Practitioners:
- Ensure that your documentation is accurate, complete, and timely as it will support that the standard of care was met.
- Document safety precautions (pay particular attention to safety with physical agent modalities).
- Notify and document any significant changes in condition that are escalated to the provider.
- Document in accordance with organizational policies and procedures (pay particular attention to requirements for assessments and reassessments).
- Amendments to the medical record are made in accordance with organizational policies.
- Refrain from making any alterations to a medical record if you are notified of an impending professional liability action against you.
- Avoid inappropriate subjective opinions, conclusions, or derogatory remarks about patients, their family members, and colleagues.
- Documentation should be congruent with the treatment plan and justify the services billed. (Services must relate directly to the written treatment plan.)
- Document declinations of care.
- Document adverse events with transparency, but refrain from placing an incident report in the medical record.
Documentation is truly one of the most important steps in the medical process. To discuss how to provide care while lessening your risk factors, please contact OmniSure.
