Documenting Therapy Discharge Recommendations in Smart Chart

By Donna Phillips, BMRH president, and Claire Small McEvoy, director, Therapy Services, BMRH

In January of 2017, a directive was given to therapy staff across the system to no longer fill in the discharge recommendation within the PT/OT Discharge planning tab in  an evaluation/treatment note in Smart Chart. The result of this process change has created inconsistent Smart Chart documentation which can be confusing to care teams at each of the hospitals who rely on therapy to give clear recommendations on next level of care for a patient.

Therapists make recommendations based on their clinical assessment of functional mobility and self-care and how these areas are impacted by the patient’s medical presentation. Nothing replaces the ongoing face to face conversations that are occurring within the daily care progression rounding initiatives across the system, however, in an effort to ensure that documentation supports recommendations, we will reinstitute therapy’s completion of this section of Smart Chart.

Please see the following discharge recommendation screen shot in Smart Chart as well as a document describing SNF vs. Acute rehab considerations to assist in the discussion during rounding.

Effective Monday, October 16th, our therapy team will resume completion of this section of the Discharge planning tab.

This entry was posted in Clinician News and tagged . Bookmark the permalink.

Leave a Reply

Your email address will not be published.