Clinical Documentation
Clinical Documentation
At the IOP Paxcampus, my only documentation is Client notes after shadowing Therapist in groups, or myself when I run group and I now am the trainee therapist on MONDAY’s only for women gender group where anything is discussed amongst women. Like PMS’ing while recovering, Relapse in/women when you are PMS’ing, codependency, depression, anxiety, fear. These notes have to be
Include a de-identified example of your documentation in this week’s paper (e.g., progress note, treatment plan).
NO REFERENCES writing on paper like you work everyday
Answer Highlighted Questions in paper.
No References, make it personal.
Clinical Documentation IOP
Topic #3:
Clinical Documentation
What are your various documentation responsibilities at your site? Groups for Women only on Mondays with a Therapist shadowing me. Student shadowing the therapist on Wednesday and Friday.
What are some of the easiest aspects of documentation? Listening etc.
What are some of the difficult aspects of documentation? When clients leave the room for U/A or One-on-One Therapy Session etc.
Include a de-identified example of your documentation in this week’s paper (e.g., progress note, treatment plan). 1. give the topic of the group, 2.write a progress note, 3.write a summary from therapist professionally.
Meet with Supervisor once a week. Tuesday or Thursday sometimes after group if she has time.
1. To discuss what you are going to talk about in Monday meeting with clients, show her a plan on paper,
2. To discuss weakness and strengths.
Clinical Documentation IOP
Introduction
Clinical documentation is the process by which a patient’s medical or therapy process is noted down in terms of the diagnosis as well as the medication and healing process. At The PAX Campus, Intensive Out Patient, I have realized that clinical documentation has the following responsibilities like daily detailed group notes, based on my interactions:
The prompt is: “What are your various documentation responsibilities at your site?” What are some of the various documents you complete at your site? group notes, Group summary by Therapist (trainee), Emails etc.
First is that it enables the center to prepare in advance, whenever a patient is to be registered for an Outpatient program, I have realized that there is the need for the facility to understand whether they can handle the case successfully or efficiently. This, therefore, means that the referral source must send the information to assigned staff and hence they will review and give a feedback within a period of seven days. This procedure is referred to as Prior Authorization.
What are your documentation responsibilities at your site in reference to Prior Authorizations? None, I am still in training. What do you have to document? Group Notes How do you get the information? By taking notes, shadowing Group Therapist. From whom? How is it to be written? Professionally Hence this type of documentation enables the center to prepare in advance the desired treatment plan.
Secondly is that the facility must understand how the progress of the patient is in terms of response to medication and or therapy. To understand this better, I/Staff must look at the Continued Stay Review which is filled after every seven days which makes it very easy to analyze the healing process. This will enable assigned staff to understand if it is best to discharge the patient or not.
What are your documentation responsibilities at your site in reference to the Continued Stay Review? NONE What do you have to document? ,Nothing How do you get the information? I don’t at this time it was just explained to me part of the training. From whom? Staff. How is it to be written? I can not answer, only verbalized.Looks like you have no documentation responsibility, only to analyze it. You are correct, only documentation is group notes on Monday unless Teresa Webb Director tells me to document on another day.
Third responsibility is that clinical documentation enables me to understand the correct time a patient is to be or is discharged. Here a Discharge Review is required to be filed which will tell when the patient was discharged and the state of his or her health. This is important for both the patient and the facility itself especially for future reference as well as legal requirements in case of a problem.
What are your documentation responsibilities at your site in reference to the Discharge review? I have no responsibilities, just a verbal conversation in training.What do you have to document? nothing How do you get the information? I do not get it I am still in training From whom? How is it to be written? Looks like you have no documentation responsibility, only to file it.
Therefore, in general, I find that proper clinical documentation helps to link the diagnosis of a patient, the current presentation, and the strategies for treatment, the progress of treatments, how the services are beneficial, the criteria for discharge and the plan.
Also, they help in writing review request that will help a reader get a current clinical state of the specific member and any other goals as well as progress of the requested review which supports the continuity of the service.
Another responsibility is that proper clinical documentation helps in identification of the correct billing status and avoid confusion that may lead to conflicts between the facility and the patient. (EMR Electronic Medical Records)
What are your various documentation responsibilities at your site versus what documentation is used for.
Some of the easiest aspects of documentation
When you complete the various documents at your site, what are some of the easiest aspects of them for you? To make sure the group notes are completed within 72 hours.
Clinical documentation is not as complex anymore since it has been infused with a lot of technical aspects that makes it super manageable. I found that at The PAX Center, there is the use of SNOMED-CT which has greatly reduced variations in the way data is captured, changed to codes and then stored for future use. This makes it easy to group related data together for research and analysis.
The second aspect is that of high performance or low latency process of the clinical narrative. Since the PAX Center is a very busy facility, it becomes very easy for the clinicians to capture large data very fast and devote their time to other functions of the facility.
Supporting the terminology query framework, here it is very easy to do queries on the system in search of information. This helps save time and is very efficient.
Unclear what this means or how it relates to what are some of the easiest aspects of documentation for you?
Also, it is easy to map out clinical expressions to other coding systems making the use of clinical data across many systems very easy and this makes data management an easy task.
The last easy aspect of clinical documentation is recording improvements in behaviors among patients, I find the human understanding aspect very efficient. Thus, all the qualified clinical documentation staffs will be able to understand any data in whichever format it may be presented through.
Some of the difficult aspects of documentation
When you complete the various documents at your site, what are some of the difficult aspects of them for you?
Lack of documentation, here I find it very difficult to keep a medical record that is not available. This means that the practitioners may have not recovered the various items that pertain a patient and this leaves a very big gap between the patent and the clinical documentation staff who may not be able to work out the issue as required. For example, lack of treatment plan may mean that a patient’s treatment procedure and the medication he or she received may not be able to be captured.
The second problem that I found to be very common is the electronic medical records that do not have narratives. Here every medical record must state what it is, who collected and recorded the data when was the data taken, is it data for a new client or a repeated client. As such one may be able to distinguish and tell the medical history of a patient. But for the case when such narratives are not there, this means that this data may be confusing and can lead to fatal medical interpretation situations.
The third challenge is that some of the clinicians even after doing their work very well and the client is getting better, they may answer or document he OASIS questions very wrongly and this may result in poor or bad payments due to the errors. Therefore, it would be best if the clinicians are trained to properly document the OASIS questions. Based on this, preventing relapse stemming from these critical environmental factors is difficult since getting proper information often pose a challenge due to privacy in families and workplace dynamics. This is existing as a major blow to treatment plans. To maintain anonymity of patients, I use registration numbers in place of actual name of patients. My method of renaming patients involves de-identification done by using years as prefixes, followed by numbers assigned to patients based on their order of admission in a given year. For instance, the first patient in the year 2018 was registered as 20180000001. I believe documentation is defined as written evidence of interactions between and among the healthcare organizations, clients and their families, and the healthcare professionals whereby the administration procedures, treatments and patient education, responses and results, are given.
The prompts are about what are your documentation responsibilities. It appears you are writing about the responsibilities of clinical documentation. DELETE What are your documentation responsibilities on the Prior Authorization, Continued Stay review, & Discharge Review? VS what are those documents responsible for providing.
Please do not forget to create documentation for group notes, and Therapist summary at the end of client group notes.
Missing a deidentified example of your documentation in this week’s paper (e.g. group notes, Topic of group, Therapist summary) At times the writing i