Question
How should therapists correctly document caregiver training?
Answer
· Document the instruction provided to the patient and supportive personnel
o Who is being taught?
o How is the teaching conducted?
o When is the teaching conducted?
o Who does the teaching?
o What is the duration of the instruction?
o Why is the instruction necessary?
I see in the documentation frequently “educated staff regarding transfers” or “educated staff to patient safety during gait.” That does not say a whole lot. When we do that documentation, who is being taught? Is it the patient, the caregiver, or the staff? How is the teaching conducted? Is it hands-on teaching? Is it in lecture? Is it a handout or webinar? When is it being conducted? Is it during the day? During daylight shift? In the evening, perhaps while the patient may be sundowning? Who is doing the teaching? Is it you? Is it an assistant who works with you? Is there a team of you? OT and PT working together to do teaching and training? How long have you done the instruction? Why is it necessary? Why do you want this person to learn this? Most importantly, what is their return demonstration? I can say that I trained this person related to safety, transfers, and correct hand placement during the transfer. I also want to follow up that that caregiver is able to return demonstrate 50% of the time. If the caregiver is the spouse and I am discharging that patient to home to live with said spouse, and caregiver is only 50% return demonstrating or compliant, I need to keep them on caseload. I think when you add that level of detail, it lends credibility to that medical necessity and why you may continue to treat them.
