Rehab managers, who are often required to hire new therapists in a shortage or crisis mode, may be in such a hurry to find their next therapist that they rush through the hiring process. However, taking time to go beyond a typical resume review and phone or personal interview may reveal problems that they will be glad they avoided. One of the more common areas of difficulty for therapists is managing an adequate speed and timeliness in documentation. Every therapist needs time to adjust to a new computer system and documentation requirements. However, one way to discover if a therapist will be proficient in this area, before you hire him or her, is to require a written assessment as part of your hiring process.
The ability to communicate with the rest of the care team through charting is an essential part of efficient patient care. In fact, the American Physical Therapy Association (APTA) has created a document with 10 pages of specific charting examples and guidelines to help therapists document correctly. As a reference to physical therapists for consistent, adequate and lawful written assessments, the APTA’s GUIDELINES: PHYSICAL THERAPY DOCUMENTATION OF PATIENT/CLIENT MANAGEMENT is very helpful. It provides an overview of the various charting scenarios you may want to include in your written assessments.
Types of written assessments
A written assessment presents the applicant with a description of a fictional treatment session and asks the therapist to write up notes for various scenarios. Using this format, you can test a therapist’s knowledge of any of the following types of documentation notes:
- Initial examination/evaluation
- Discharge or discontinuation summary
Qualities of well-written assessments
An assessment written by a therapist with good writing skills will have evidence of the following qualities:
- Complete documentation of the patient and the attending therapist’s identity and history
- Numbers and facts to explain the treatments used
- Specific detail about the patient’s response to treatment
- Accurate spelling and grammar usage
- Clear and concise writing style
Are you looking for physical or occupational therapist, or a speech language pathologist?
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