Practical Tips When Professions Collide

Documentation. It’s the written proof of your professional work. How many times in nursing school did you hear the admonishment, “If you didn’t document it, you didn’t do it”? I know it still rings in my head, along with other phrases like “Your handwriting is too fancy” and “Your e’s looks like i’s.” The phrase certainly brings back some fond, and perhaps some not so fond, memories. But I am of the opinion that the art of documentation continues to be one area in which all medical professionals can improve. As you will read below, each particular area of practice requires varying degrees of documentation and unique language for the respective areas.

My experience in documentation began with my first job out of nursing school on the traditional med-surg floor focusing on the assessment of post-surgical issues such as vital signs, wound management, neurological status, I and O, etc. Once I felt comfortable and confident with those skills I moved on to the surgical ICU, which demanded much more keen assessment skills and brief but extremely detailed documentation.

Following my time working in the surgical ICU, I moved into home care. The documentation required for a home care nurse demands looking beyond the patient and including the environment in which the patients live, including ADL’s, safety and family involvement. Considering I had just come from a situation in which most of my patients were comatose, my documentation skills were certainly tested.

Then one autumn day I received a call from a colleague who urged me to become a case manager. No weekends, no nights, good pay and sometimes a company car. I thought to myself, how in the world could I resist this opportunity? Or is this too good to be true? Despite my questions, so began my career as a workers’ compensation nurse case manager.

Over the past 14 years working in this arena I have learned a lot about documentation related to this area of practice. Working outside of the acute hospital or home setting requires attention to other detail besides the obvious medical conditions, signs/symptoms, medication list, diagnostic results, etc. The workers’ compensation system requires documentation related to compliance with treatment, attendance at physical therapy, current work status, availability of modified duty and physical demands of their job. Most of these are not things we learned about assessing in nursing school. In my opinion, workers’ compensation case management requires a delicate balance of being a patient advocate who assesses, monitors and plans health services, as well as a medical liaison and educator.

As my career recently moved me into the world of rehabilitation, I now have the opportunity to share my knowledge of workers’ compensation documentation with my therapist colleagues. I certainly do not discuss with a physical therapist how to treat a rotator cuff injury, or any another medical condition for that matter, but I do occasionally share with them how to make sure their documentation reflects appropriate information that is needed for nurse case managers as well as employers and adjusters. Again, information includes the patient’s current work status, the physical job requirements for returning to work, why the patient might have missed an appointment and, of course, the patient’s objective functional progress. It is imperative that a therapist document, and nurse case managers ask about, the detailed skill involved in the patient’s treatment plan. If skill is not documented, then the necessity of therapy may be in question.

Working with physical and occupational therapists has allowed me to view a more detailed and different side of the medical treatment for a work-related injury. It is an area that allows a significant amount of interaction with the injured worker, thus allowing more opportunity for specific documentation. I appreciate the relationship a therapist has with her patient and would not jeopardize that in any way, but sometimes simple education or reinforcement between professionals can prove to be a valuable tool. After all, a physical therapist in the outpatient setting may see many different types of patients, each one requiring certain types of information that must be documented. Through my work with physical and occupational therapists, I have recognized that we can be a collective resource for each other, both striving to reach the same goal of returning an injured worker to his or her optimal level of function.

Donna Foley, RN, CCM, is the senior business development manager with Select Physical Therapy.