1. Referrals & Other Forms of Documentation KNR 279 Shank & Coyle, 2002 Stumbo & Peterson, 2004

2. 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

3. 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

4. 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

5. Incident Reports  Accidents  Elopement  Behavior problems  Completed immediately after incident  Not in record  Write objectively with details  Avoid opinions  Don’t assume blame

6. Other Reports  Numerous forms of documentation Attendance Others??

7. Computerized Documentation  Becoming more frequently used  Improve legibility  Decrease repetitive writing  Decrease errors & time  Greater access Don’t have to fight over charts