Name of the Procedure:

Documentation of a Positive Functional Outcome Assessment without Documented Care Plan (G8543)

Summary

This procedure involves recording the results of a functional outcome assessment that indicates positive progress or improvement. However, it notes that a follow-up care plan was not created, and no reason was provided for this omission.

Purpose

The purpose of this procedure is to document the findings of a functional outcome assessment. This helps track patient progress and guides future clinical decisions.

Indications

• Patients undergoing rehabilitation or treatment for physical impairments.
• Monitoring progress in patients recovering from surgery or injury.
• Evaluating the effectiveness of therapeutic interventions.

Preparation

• No specific preparation is required for the documentation itself, but the functional outcome assessment may involve preparatory steps such as completing questionnaires or physical tasks.

Procedure Description

1. Conduct a functional outcome assessment using a standardized tool such as a questionnaire or physical performance test.
2. Evaluate and record the results of the assessment, indicating positive functional outcomes.
3. Note that no care plan has been documented and provide the reason why if possible. In this case, no reason is provided.

Duration

Typically takes 10-30 minutes to complete the assessment and documentation, depending on the complexity of the assessment.

Setting

This procedure is commonly performed in outpatient clinics, rehabilitation centers, or during routine follow-up visits.

Personnel

• Healthcare provider conducting the assessment (e.g., physical therapists, occupational therapists, rehabilitation specialists).
• Administrative staff for record-keeping.

Risks and Complications

• Minimal risk involved in this documentation process.
• Potential oversight if positive outcomes are noted without a corresponding care plan, which could delay further necessary treatment.

Benefits

• Tracks patient progress effectively.
• Provides critical data for ongoing clinical evaluations and decisions.
• Helps ensure a record of patient improvement, which can be motivational for both patient and care providers.

Recovery

• No recovery needed for the documentation itself.
• Post-assessment care may involve specific interventions based on the assessment’s findings.

Alternatives

• Documentation with a detailed care plan.
• Using different standardized assessment tools based on patient needs.

Patient Experience

• Patients may feel encouraged by documented progress.
• Clear communication from the healthcare provider regarding the lack of a care plan is essential to avoid confusion.