A clear statement of those outcomes in the patient record also makes it easier for floating staff to clearly document progress. Cindy Tanenbaum, MHA,OTR, a project manager with Washington, D.C.-area HMO Mid Atlantic Medical Services Inc., agrees. If there s no goal for what you re doing, Rowell said, you shouldn t be doing it. She suggested that you ask yourself what you hope to achieve with a particular treatment. Progress toward that goal should then be documented.
Clinicians know that charting can be time-consuming.
In Southern California, staff at Kaiser Permanente were spending more than 40 percent of their time on documentation, said Christine Zingo, MS, assistant medical group administrator with Permanente Clinical Systems Development for Southern California Permanente Medical Group in Pasadena, California. So they implemented care paths and charting by exception, in which only deviations from the standard course of treatment are charted. Tanenbaum said clinical pathways can facilitate insurance companies approval of treatment plans and make it easier to see which outcomes are being achieved. Standard documentation when charting by exception includes the expected route of recovery, so outcomes are easily identifiable. But not everyone accepts clinical pathways, charting by exception, or other formats.