Summary form helps discharge planners
Therapists check off items during evaluation
An interdisciplinary discharge summary form developed by the rehab services staff at Sharon (PA) Regional Health System has cut down on paperwork for therapists, and ensures that therapists at the next level of care receive patient information in a timely manner.
The new form was designed by a rehabilitation program improvement team made up of representatives from physical therapy, occupational therapy, speech, recreation therapy, and rehab nursing. It replaces five separate forms previously used by each discipline.
The form goes to the referring physicians, and therapists in other parts of the continuum, such as outpatient centers or home health. In the past, therapists in the next venue of care had to wade through as many as five different lengthy forms, none of which were alike, to get information about the patient.
Therapists would write progress notes following the discharge evaluation, and fill out the discharge form later. They had a week to fill out the discharge evaluation forms and forward them to the next level of care. Often, patients had received several outpatient or home health treatments before the discharge summaries arrived, explains Barbara Cogley, RN, CCRN, NHA, coordinator of rehab services.
"A discharge summary isn’t a functional tool if it isn’t filled out during discharge and sent with the patient," she points out.
The committee compiled all the discharge forms being used, decided what items should be included, and hammered out a format, Cogley says.
"They needed to find something that was efficient and effective. Some of the summaries were very detailed and lengthy and it took the therapists a long time to fill them out," she says.
The new form is part of the patient record and goes with the patient to the discharge evaluation from each discipline. The therapist must fill it out during the discharge evaluation.
The discharge form contains the 18 items in the Functional Independence Measure (FIM, administered by the Uniform Data System for Medical Rehabilitation in Buffalo, NY), along with 21 other items such as social support system, skin integrity, compliance, social interaction, oral strength, and memory.
The discipline that is most involved with each item scores it on a seven-point ordinal scale. For instance, occupational therapy would score the eating, grooming, and bathing items. Recreational therapy would score the leisure behavior items.
There is a space by each item for comments. In addition, there is a large space for comments from each discipline, including information on education provided, instructions given to the patient and family, and equipment provided.
[Editor’s note: For more information on Sharon Health System’s health assessment forms and transdisciplinary discharge summary, contact Barbara Cogley at (412) 983-3911, ext. 4002.]
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