The Memory Unit OT

Working in the skilled nursing setting, sometimes evaluations can either be really straight forward or feel like they take a literal million years. Especially when someone has been in the hospital for many months (and sometimes even been bounced around to multiple hospitals and/or other skilled nursing facilities), and they come into your care with the world’s longest medical history packet.

If you’re someone who is detail oriented, it can take over 45 minutes just to comb through the medical history to complete the initial portions of your evaluation, all before you even meet the patient.

I’ve created a Quick List to help me collect data as efficiently as possible, without getting bogged down by some of the extra information that may not be directly relevant to my therapy evaluation. It’s just a way for me to be as thorough as I can while also trying not to waste too much time on the chart review.

Then, I use these three basic strategies to help me gather the information.

First, I talk with the nurse who received verbal report for the patient. Typically, a nurse from the transferring hospital will call the SNF once the patient is on their way, letting the nursing staff at the SNF know that the patient is in transport and the basics of what to expect. These reports are usually a quick run-through of information but will including things like precautions, current transfer status, cognitive/safety recommendations, and diet texture modifications.

Then, I immediately start combing through the medical history paperwork in search of the therapy evaluations. The therapy notes are my first stop for a few reasons: 1) therapy evaluations typically have the primary diagnosis right at the top, 2) the reason for referral to acute level therapy will give me a quick, one to two sentence summary on why the patient was brought into the hospital, and 3) I’ll be able to see a quick summary of their home context and their assist levels at time of hospital/acute rehab admission (which usually gives me an idea of how sick this person actually was).

Once I have this information, I start combing through the rest of the paperwork. Typically I’ll start by looking for any long narrative sections. Longer narratives are often written by the admitting and/or discharging doctor, and give a basic summary of the reason for hospital admission, how the individual got to the hospital, and any factors that complicated the hospital stay.

At this point, I usually feel pretty confident with the information I have. Any further data collection is just to fill in the gaps or blanks in the story line.

Now, the reality is not every medical history will be thorough. Sometimes I go through a huge stack of admission paperwork only to find that it’s the same 12 pages photocopied 10 times. Other times, the incoming information is very minimal, in which case I’m forced to get most of the medical history and hospital stay information directly from the patient (and hopefully their memory is good). And to be honest, I only see a hospital discharge summary with about 50% of the admissions I evaluate.

All this to say, sometimes the information just isn’t there, and we have to do the best with what we’re given. If you struggle with chart review, I hope this free tool gives you some direction and structure. And always remember that the rest of the interdisciplinary team is trying to get to know this patient too. Don’t be afraid to collaborate and ask questions. You’ve got this!