Lagniappe Seminars

Course Locations:

Date	Location	Place	Phone #
TBD	TBD	TBD	TBD

Course Description:

Far too often, our patient care documentation is done at the last minute. You see your patient, you offer quality patient care to address the needs of your patient, and then you hurriedly write your note and get it signed so you can get to your next patient. Too often, the notes that are supposed to tell the complete story of what you are doing as a skilled provider, do not do this. Now, at a time with increased scrutiny of our notes, this seminar becomes ever so important.

In this seminar, we will go over the importance of complete documentation and what should be included in a patient record. We will introduce RAC and what it means to therapists. We will discuss what all needs to be included in a patient evaluation, a progress note, in a re-assessment, and a discharge summary. We stress the role of the progress note as a tool to protect the therapist and to protect the patient.

Course Objectives:

Participants will be
Aware of the importance of complete and accurate documentation.
Aware of what needs to be included in a patient record.
Aware of RAC and understand their role in the RAC audit.
Know what needs to be included in a patient evaluation.
Know what needs to be included in a progress note
Know what needs to be included in a re-assessment
Know what needs to be included in a discharge summary.
Be able to review a note and know if it is deficient.

Course Schedule:

At the present time, this seminar is offered on-site only in AR and LA

1st hour: introduction. pretest

		RAC-Who are they? What do they do? Why is therapy a RAC target?
		Documentation is a skill
		Documentation is a professional responsibility
		Medicare documentation requirements
		Components of a medical history
		Components of objective tests/measurements/systems review

2nd hour: Goal writing

		What is a prognosis
		Plan of Care
		Components of progress/treatment note

		what to include?
		what demonstrates a skill?
		does the assessment show skilled observation?
		how to document plan for following visits?

		Re-assessment--why?
		what to include?
		Discharge summary--

		APTA guidelines
		Review of 2 treatment notes
		Group discussion of notes
		Post test

Lagniappe Seminars is a trade name under Melvin Physical Therapy, Inc.

Prior Approvals:

last updated list 6/05/2010

Approved by AR State Board of Physical Therapy for PT/PTA 2 contact hours

If your state is not listed, or if there is a question regarding approval in
your state, please contact Lagniappe Seminars or your licensing body.

Testimonials:

This is a letter of recommendation for the inservice Documentation-The Cornerstone of Quality Care which Anne Melvin, Physical Therapist, delivered for our agency. This was an excellent educational tool for our physical therapy team as well as for the nursing and management staff.

In this time of increased scrutiny of the documentation done by therapists for the Medicare home health patients, it was extremely useful to have such an in-depth inservice presentation. Anne has been delivering physical therapy services in the home setting for many years and is a very knowledgeable resource. This recommendation of her program is given without any reservation concerning its worth.

Sincerely,
Joyce Hines, RN, Administrator
Prime Care Home Health