HCPrac

6/14/99

Why we document?

• Good pt care
• Pt progression
• Legal reasons
• Communicate w/other doctors
• Insurance companies
• Deadman notes
• Prove pt needed the care
• Dx of the pt
• Attorneys
• Quality assurance
• Improves clinical competency

Unprofessional Conduct

• Your ethical responsibility:
• Truthful
• Accurate
• Complete

• Failure to do so is "unprofessional Conduct

Confidentiality and Informed Consent

• Do not use the pt's name
• Need to be more conscious about this
• Pt has the legal right to release information
• Need consent signed before sign pt
• Need it in writing

Informed Consent

• When is it obtained?
• Needed before pt is touched
• Detailed one comes after the Report of Findings

1. benefits of tx
2. risks due to tx
3. alternatives to the tx

Informed Refusal

• informing the pt that they may get worse w/o tx or w/over-the-counter meds

POMR

• problem oriented Medical Record

SOAP

S—subjective

O—objective

A—Assessment 1)Dx (w/code #) 2)progress 3)

P—plan

Folder of pt Forms

• SOAP note does not go on the yellow hx form
• Sensory—intake
• Sign—present or not present
• Test—always right something w/the + or –
• Treatment plan
• Goals
• Supportive care—active care
• Treatment—passive care on the pt, active is what the pt does