Eli's Rehab Report

Published on Tue May 24, 2011 PDF

Multiple forms won't suffice when surveyors come knocking.

You can spend weeks preparing for a joint commission survey, but you should still expect a citation if therapy patients' records are missing one key item -- a summary list of treatment information.

What it is: The summary is a document that is "readily available to all practitioners and updated whenever there is a change in diagnosis, medications or allergies and whenever a procedure is performed," the Joint Commission states in an FAQ on its website. Though the summary requires more time, the end result is important, stresses Agnes Papa, PT, director of rehab for Bert Fish Medical Center in New Smyrna Beach, Fla. "This list ensures that, in case of emergency, there is a summary of the medical history along with all information about the current condition you are treating," she says. The list also provides a structured process for noting and escalating any emerging problems or conditions.

Important: Having all the pertinent information on several different forms won't work, notes Mark Dwyer, PT, MHA, director of rehab services for Olathe Medical Center in Kansas. Surveyors "want all the data on one form," he says. If a surveyor has to search for the information, then so will your staffers -- and that could lead to crucial data getting overlooked. Luckily, creating and maintaining a patient summary list isn't that difficult -- though the process can be redundant. Here's help:

Start Your Summary at the Evaluation Stage

Your clients' records may already have a patient summary. If so, your job is simply to keep the summary updated. But if the records don't bear a summary, you have only three visits to create one, the commission states.

Best bet: "We initiate the patient summary at evaluation," Papa shares. This way, treatment kicks off with all the available information -- and the form ensures communication across disciplines, she says.

Give patients and their families a questionnaire that asks for surgical and medical history as well as a list of medications. Combine that information with any data contained in an electronic medical record.

Next step: Create your list from the information on the questionnaire and what your staff uncovered during the evaluation. Initial and date each entry.

Put Therapist - Only -- In Charge of Summary

Though your registration staff could gather the information you'll need for the patient summary, a therapist is the best person for the job.

Why: A therapist is trained to spot potential problems and will know the next best steps to take after getting in-depth background information on a patient, Papa states. The therapist will also know whether another diagnosis is necessary or when to flag other disciplines.

Bonus: Therapists can use this time to ask questions that might root out problems, notes Laurie Martin, senior director for Bluffton Medical Services in South Carolina. "We've trained therapists to use our form to screen for any unfinished home health episodes," she says.

If it appears the patient hasn't yet been discharged from an episode, the therapist then helps the home health agency with care coordination so the patient can be seen as an outpatient. The patient may also choose to delay treatment until they are discharged, she says.

Standardize Your Summary Location, Too

Once the therapist has combined all the crucial information, ask that the list be stored in a standard location in patients' records so that it's easily accessible, Dwyer suggests.

Example: "We attach a hard copy of the summary to the back page of the paper chart," Papa says. After discharge, the summary and all other paper documentation is scanned into the electronic records system.

If you don't use paper records, you could maintain the form electronically -- but each staffer involved in patients' care must know exactly where and how to access it, Dwyer notes. Otherwise, your surveyors won't be satisfied that they can act fast when an emergency arises.

Resource: See a sample patient summary list on page 37. For more information about the Joint Commission's requirements, go to www.jointcommission.org.