Referrals & Other Forms of Documentation KNR 279 Shank & Coyle, 2002 Stumbo & Peterson, 2004
Need For & Purpose of Referrals Referral Formal request for services In client record To TR Often from doctor Initiates treatment From TR Support from other disciplines May be part of D/C plan
Therapeutic Recreation Discharge and Referral Process ITRS, 1990 Standards & guidelines Effort to improve leisure services & improve communication between clinical and community settings Notes importance of clinical & community collaboration Easier in Chicago & suburbs Very important as LOS decrease
Therapeutic Recreation Discharge and Referral Process TR within clinical settings D/C & referral standards & guidelines Steps to follow to establish a referral system in a clinical site TR within community settings D/C & referral standards & guidelines Steps to follow to establish a referral system in a community site Sample forms
Incident Reports Accidents Elopement Behavior problems Completed immediately after incident Not in record Write objectively with details Avoid opinions Don’t assume blame
Other Reports Numerous forms of documentation Attendance Others??
Computerized Documentation Becoming more frequently used Improve legibility Decrease repetitive writing Decrease errors & time Greater access Don’t have to fight over charts