Therapy Documentation, ListServ Summary, Aug 2023
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):
- Does your facility use Epic to document?
- If yes, for daily documentation, are you using smartphrase based notes (text heavy), notewriter, flowsheets, or some other feature to document?
- 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?
- Does your daily session documentation look the same or different than a progress note (which may be completed periodically—see next question)?
- Does it have the same fields for documentation or different?
- Do clinicians complete progress notes to summarize multiple sessions? If yes, at what frequency is this progress note documentation completed? Monthly? After # of sessions?
- 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?
- If you use Epic, do you document goals in “Patient Goals” or “Goals” activity specific to Epic?
- Are you using Q-Global for administration of assessments? What barriers or successes have you found with this?
- Do clinicians have the option for dictating into your EMR?
Summary of Responses (De-identified)
