Interdisciplinary form aids discharge process
Therapists check off items during evaluation
An interdisciplinary discharge summary form developed by the rehab services staff at Sharon (PA) Regional Health System cuts down on paperwork for therapists and ensures that therapists at the next level of care receive patient information in a timely manner.
Designed by a rehabilitation program improvement team made up of representatives from rehab nursing and physical, occupational, speech, and recreation therapy, the new form replaces five separate ones previously used by each discipline.
The forms go 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 lengthy forms, all different, to get information about the patient.
Therapists wrote progress notes following the discharge evaluation, then filled 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 says.
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 a 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 most involved with each item scores it on a seven-point ordinal scale. For instance, occupational therapy would score eating, grooming, and bathing items. Recreational therapy would score the patient’s ability to do leisure activities.
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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