Rehab administrators answer questions regarding Therapy Documentation. IPRC archives information collected by the Pediatric Rehab Administrator’s ListServ as a public service to the entire Pediatric Rehabilitation Community. All information is posted in summary format and has been de-identified. Search through past queries for responses to rehabilitation related questions.

Original Question(s): 

1. Does your facility use Epic to document? 
2. If yes, for daily documentation, are you using smartphrase based notes (text heavy), notewriter, flowsheets, or some other feature to document? 
3. Do you use the same templates regardless of setting (inpatient acute, inpatient rehab, outpatient) or do the templates vary depending on setting in which the patient is being treated? 
4. Does your daily session documentation look the same or different than a progress note (which may be completed periodically—see next question)?  
5. Does it have the same fields for documentation or different? 
6. Do clinicians complete progress notes to summarize multiple sessions?  If yes, at what frequency is this progress note documentation completed?  Monthly?  After # of sessions? 
7. Does your patient discharge documentation look the same or different than a daily session note?  Does it have the same fields for documentation or different? 
8. If you use Epic, do you document goals in “Patient Goals” or “Goals” activity specific to Epic? 
9. Are you using Q-Global for administration of assessments?  What barriers or successes have you found with this? 
10. Do clinicians have the option for dictating into your EMR? 

Summary of Responses (De-identified)