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Lecture #7.docx - AHSC 450: Therapeutic Recreation...

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AHSC 450: Therapeutic Recreation Assessment and Leisure CounselingLessonReadingsGoogleLecture #7Documentation and ChartingDocument and Charting-The primary reason for covering the topic ofdocumentation and chartingis that writingin the progress notesisa statement of assessment–the ongoing assessment of the patientsstatus.Question-What is the difference between charts and assessments?On-Going Assessment
-In addition to the results of a particular assessment, a TR specialist can contribute to theclient’s progress notes throughout the course of his/her stay or enrollment in a program-TR specialist can....oChart the patients ongoing progressoCommunicate with other members of the team through notesoBuild a case for or justify services received by the clientoImplement specific information that may not be known by other team members
Basic Rules of Documentation-Accurate recording of all events – TR can vouch for-Documentation should be implemented in a timely manner-Sign and date all error corrections-Sign and date all entries-Keep documentation professional-Documentation should be done frequently & consistently-Documentation should be concise and patient/client specific-Documentation should be profession specific-Documentation should be descriptive-Documentation should be clear and well writtenPatient/Client Contact-Three ways a TR specialist can initiate patient contact.oWhole unit (or service) coverageThe first way is when the recreational therapist is responsible for seeing allthe patients on a unit. In this case the therapist is expected to make a basic,formal evaluation of the patient’s needs between the first and seventh dayafter admission.The therapist ill need to determine which patients require the mostimmediate care.These priorities are based on the results of an assessment combined withprofessional judgment.The type of assessment and the degree of recreational therapy interventionrequired should be placed in the progress notes section of the medicalchart.In some cases the therapist will want to document that s/he will provideongoing monitoring to evaluate the need for initiating services throughoutthe admission.oReferralThe second manner in which a therapist may initiate contact with a patientis through a referral. A referral is a formal request (in writing, usuallydocumented in he medical chart) from another person who has legitimateinterest in the treatment of the patient.A member of the treatment team, a legal guardian, or the insurancecompany or trust fund supervisor may refer a patient to thetherapist.

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