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Next Reply: Re:Documentation for IDT meetings
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Post Documentation for IDT meetings
Author: MarjT
Date: May 27, 2009 11:19 am
Would it be possible to get some input regarding the documenation of patient discussions within your IDT meetings? Are there recommended guidelines to what needs to be documented and where? I have seen everything from "Plan of care reviewed & updated" with team signatures to more complex documentation addressing signs/ symptoms/ goals of care, etc. Does each institution and/ or team determine their own policies? We have a small team, and part of our concern is no clerical support. Thank you in advance for any and all assistance.
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+ Re:Documentation for IDT meetings (by mrabow on 05/28/2009)
Hi,

I'm not aware of specific requirements for palliative care team meeting documentation... if someone is, please let us know.

But, IDT involvement in the assessment and care provided are a huge part of the quality imperative for palliative care. And, as a general rule, if it's not documented, it didn't happen.

A few recommendations:

(1) Documentation requirements are often a local issue (based on hospital policies)... so checking with your hospital is key.

(2) Minimal documentation would be a listing of all the patients discussed at a meeting and all those in attendance.

(3) Confidentiality is a major focus: our hospital has all the attendees at our meeting sign in at each meeting with their signature attesting that all the patient info discussed at the meeting will be held confidentially.

(4) A record of the team's recommendations should be documented somewhere... typically in a formal consult note back to the referring clinician. For billing, this is required. This then becomes part of the official medical record.

(5) From a program growth perspective, the more pc has their notes, thinking, and expertise seen by other clinicians, the better. To the extent that teams are able, publicizing their sophisticated and compassionate discussions and recommendations to other clinicians in the medical center is a great thing.

Best,
Mike Rabow, MD
Associate Director, UCSF Palliative Care Leadership Center.

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