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Massage Today
August, 2012, Vol. 12, Issue 08

Documentation in Hospice: What Do Employers Expect?

By Ann Catlin, LMT, NCTMB, OTR

Hospice organizations that hire or contract massage therapists expect professionalism. They expect sound documentation skills. Although there isn't a lot of consistency in how documentation is carried out, what IS consistent is the requirement to do it, and do it well.

I once spoke with a hospice director who told me, "We use to have a massage therapist but it didn't work out." When I asked her what went wrong, she said one reason was that, "her documentation was poor quality." The take-away message here is: Sharpen your documentation skills and accept that it is an important part of the job if you want to work in any aspect of our health care system.

Why Document?

The main reason you became a massage therapist most likely wasn't because you were excited about doing paperwork or writing progress notes. Ask any nurse or physical therapist or physician and they will tell you it isn't their favorite thing, either. I've found if I re-frame my ideas about documentation, then an attitude adjustment is quick to follow. What follows are good reasons to pay close attention to your documentation skills.

Credibility: How you represent your work in progress notes reflects your degree of professionalism in the eyes of employers and coworkers.

Documentation - Copyright – Stock Photo / Register Mark Efficacy: Progress notes provide a means to track effectiveness of techniques or approaches in attaining desired goals.

Functional Outcomes: Your notes tell a story, over time, about the difference massage makes in your client's activities of daily living.

Improved relationship with colleagues: When your documentation provides valuable information for coworkers, your work is taken more seriously and you demonstrate that you are a team player.

Legal record: Documentation is your legal record of the services you provided.

Marketable skills: When applying for a position in hospice, highlight experience you have with healthcare documentation.

Don't just take my word for it. I did an online search for massage therapy jobs in hospice and in almost all notices job requirements referred to documentation skills. It's also worth noting that the number of job notices online is growing. Here are a few examples taken from postings that mention expectations with regards to documentation:

  • Document patient treatments, needs and progress with accuracy and clarity.
  • Reviews patient's chart and all medical history prior to initiating treatments.
  • Documents all patient visits according to charting policies and procedures.
  • Submits periodic reports to treatment team or physician to provide clinical data for evaluation.
  • Maintain accurate and timely progress notes in the activities section of the medical chart.
  • Basic computer skills to include Outlook, Microsoft Office and Windows.

Keeping SOAP Notes Simple

For those of you whose eyes cross at the mention of progress notes, I want to offer a simple guide that is relevant to hospice. Since many use SOAP notes, it's likely you will be required to use this format. Think of a SOAP note as a picture of the session, showing the reader what you observed of your client; what you did, how your client responded and what you plan to do for future sessions.

S = Subjective information. In this section, record verbal comments your client makes about any of these things: their reason for and desired outcome of the session; a description of symptoms; the effect of symptoms on activities of daily living; and pain levels or other discomfort. It's common for the hospice care team to determine levels of pain using a pain scale the Wong-Baker Faces and Ruler Pain Rating Scale. You should also record any other relevant comments by the patient or family caregivers.
There are times when a client, due to an advanced condition, is unable to provide such information, in which case it might be reported to you by a nurse, physician or other team member. In this case, you would state that the client is unable to verbalize the information but it was reported by (name and title of informant).

O= Objective observations. This section includes both observations of the client and what you did during the session. Describe just the facts about your observations — only what you can see, hear, touch or smell. Observations might include, but are not limited to special communication needs; breathing patterns; movement; muscle texture; functional mobility; body posture or position; skin condition; facial expression; sign of stress or agitation; interpersonal interaction; alertness; observation of confusion or memory loss; and non-verbal signs of pain.

The record of what you did should include information about site restrictions, precautions taken, the length of the session, bed or wheelchair positioning adaptations performed, massage or bodywork techniques that were utilized and which area of the body was addressed.

Descriptive language of the techniques used could include: focused touch, gentle compression, petrissage/kneading, effleurage/stroking, gentle stretching, holding, shared breathing, gentle rocking, moisturizing, abdominal massage, manual lymphatic drainage, energetic modality and caregiver instruction or support.

A= Assessment. Record the immediate results of the session including observed client responses and changes. Examples of observable responses might include signs of decreased pain; positive verbal comments; decreased agitated behaviors; fell asleep; increase in social interaction; appears more engaged; decreased muscle tension; relaxation response; deeper breathing; appears more alert; change in facial expression; improved movement; postural change; skin changes; returned touch; and improved ability to perform an activity of daily living.

P=Plan. This section includes information relevant to the treatment plan, including frequency of future sessions; additional client needs; treatment recommendations for future sessions and desired outcomes; client requests; and a need for caregiver instruction.

On the Job

I interviewed several massage therapists employed in hospice or long-term care about what documentation is required of them. As expected, it varies a great deal. Some organizations use electronic systems and more organizations are transitioning to electronic record keeping. Some organizations provide the therapist with documentation forms developed by the company. Other therapists must provide their own forms. Some use a structured SOAP note form with checklists, others write narrative notes or a combination of the two. Most organizations place the therapist's documentation in the medical record or other patient chart.

Valerie Stoughton Hartman is a Complementary Therapy Hospice and Palliative Care Nurse and Chairman of the National Hospice and Palliative Care Organization (NHPCO) Allied Therapy Section. She says that complementary therapies have taken a place in mainstream services provided by hospice programs in the United States. While many hospices appreciate and grow volunteer complementary therapy programs, others remain committed to hiring hospice prepared therapists.

When it comes to documentation, the industry is in the midst of figuring out best practices. As it stands right now, documentation standards are dictated by each individual hospice program. Administrators make executive decisions in order to assure accurate documentation reflects the purposeful use of a modality. Hired therapists have a responsibility in the referral process, interdisciplinary team communication, evaluation, assessment and provision of service. Volunteer expectations are often much less demanding. The NHPCO is a resource for program development if a massage therapist volunteers or is hired to work with a hospice program that is a member of the organization.

I agree with Valerie when she encourages massage therapists working in hospice to join the NCHPP Allied Therapy Section, which oversees allied therapy and complementary therapy use and integration in end of life care. We can all have a voice in establishing best practices in this rapidly growing field of massage.

Sources:

  1. The National Council of Hospice and Palliative Professionals (NCHPP) is an interdisciplinary-focused and discipline specific forum supporting hospice and palliative care professionals and volunteers through the provision of resources, education, and networking opportunities.
  2. Thompson, Diana (2011) Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists, Lippincott, Williams & Wilkins, Philadelphia, PA.

Click here for more information about Ann Catlin, LMT, NCTMB, OTR.

 

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