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Write Right and Do Right Efficient Note Writing


Write Right and Do Right Efficient Note Writing

Due to the constraints on our time and pressure for efficacy, physical therapists cannot afford the luxury of writing lengthy notes or utilizing tests that have no applicability, such as some of the tests used in the examination of back pain.

Lewis cut

An article by Michael Alexander published in Spine (1997; 22(3):296-304), explores physical tests often used to determine the severity of back pain reported by a patient. The authors found that several of the tests performed by therapists had no relationship to the severity of the patient's back pain. The tests that proved to be salient were rotation, lateral flexion, finger floor distance, position of postures related to plumb line pain, percussion of the spine, and hand muscle strength.

Those creating standardized forms for our profession frequently use and advocate reflex testing and abdominal strength tests. However, these tests show no consistency for determining patient complaints of pain. One reason for this problem is the unreliability of manual muscle tests and abdominal strength tests. Reflex tests may not be indicative of back pain severity, because reflexes are not an important variable in a large percentage of the population. Consequently, we must question whether it is important and appropriate to do all of the numerous tests for evaluating the low back.

When I see new students in the clinic, I witness them wasting their time testing all the reflexes and doing manual muscle testing for every joint in the body even though the complaints may be limited to the back or lower extremity. The students then do not spend enough time doing functional assessment measurements, the specific tests necessary to formulate hypotheses through evaluation of the patient. This over utilization of tests makes many therapists' record notes that are lengthy and verbose. When reviewing notes for payers, it is disheartening to read pages and pages of information even though every test is negative.

As a profession, we must recognize those few tests that should be done at a minimum and build from there, based on indications from a bare bones evaluation. We lose our ability to be good therapists if when we spend hours doing an evaluation and writing lengthy notes with numerous negative implications only to transpose that to a piece of paper without any indication of what needs to be done. It is most important to provide succinct, precise and informative data.

My notes for initial, progress and discharge are limited to one page in order to provide specific objective information. A two-page lengthy history that does not indicate significant details is not helpful to the patient or therapist. Information written in the chart should be appropriate and pertinent. For example, a patient may have a significant postural deviation, such as a 5/10 forward head based on Reedco Posture Score Sheet. If I expect to change this posture with exercises and interventions, then this is an appropriate subject for notation. The scoliosis may also be appropriate to list in the statement of impairments or goals if it is impacting the patient's shoulder problem, and the apex of the curve is in such a position that 150 degrees of shoulder flexion will never be achieved. However, if I am listing a 5/10 scoliosis that I cannot enhance, change or modify to improve the patient's shoulder problem, there is no point in listing it in the notes.

In an effort to improve our skills, therapists should work together to critique each other's notes and provide significant feedback regarding what is necessary within these notes. This practice will train us to write down only what is important. As a profession, we would be providing more succinct and appropriate information to our peers. Time and pressure make it necessary for us to streamline our notes in a reasonable, professional fashion. This streamlining is incumbent on us, and we must not allow the insurance companies or national associations to dictate what must be in our notes.

As a profession, we must provide appropriate treatment based on succinct and clear notes. Take the time to meet with your colleagues in the office setting, at documentation seminars, or in outside interest groups without fear, false pride or inflated commitments and honestly review and develop a system of appropriate documentation that works for you.

* About the author: Dr. Lewis is a clinician and owner of Physical Therapy Services of Washington, DC. She lectures exclusively for GREAT Seminars and has published more than 13 textbook and 300 articles that are available from Learn Publications.

Study Supports Use Of Soft Cast

Sometimes the soft touch is the most effective. It seems to work with avulsion fractures at the base of the little toe, anyway.

Bradley D. Wiener, MD, director of sports medicine, Catskill-Orange Orthopaedics PC, Ferndale, NY, authored a study on the subject that appeared in the June issue of Foot and Ankle International, the official journal of the American Orthopaedic Foot and Ankle Society, Seattle. The general conclusion, according to an AOFAS news release, was that "treating a common foot fracture with cloth padding bandages rather than a hard fiberglass cast will significantly speed the recovery of most patients." The fractures treated with the soft dressing were found to recover 40 percent faster than those treated with fiberglass casts.

Dr. Wiener and his co-workers randomly treated 89 patients with avulsion fractures entering the emergency department at St. Vincent's Hospital in New York City, and followed up with the study group extensively during their recovery period. Patients received either an inflexible fiberglass cast or an immobilizing dressing of a binding layer of cloth padding, an Ace bandage, another layer of cloth padding and another Ace bandage.

Those who received the "soft" treatment returned to full, preinjury activity in an average of 33 days. Those with the fiberglass cast took about two weeks longer to return to full activity.


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