At QUAD A, we are committed to supporting our clients in meeting the highest standards of patient care and documentation. One recurring challenge identified during surveys is the documentation of the extent to which the patient is aware of their diagnosis(es) and prognosis in the creation of the Plan of Care (POC). This issue is particularly relevant in Physical Therapy (PT), Occupational Therapy (OT), and Speech Pathology practices, where documentation formats vary widely. Together, we can ensure that every patient feels informed, involved, and confident in their care journey by improving how we document their awareness and participation in the POC.
This newsletter aims to:
- Highlight the importance of documenting the extent to which the patient is aware of their diagnosis(e) and prognosis in the POC.
- Provide guidance on avoiding "boilerplate" language that may compromise credibility.
- Offer practical tips for aligning documentation with QUAD A standards.
Standard 15-D-8 requires “The extent to which the patient is aware of the diagnosis(es) and prognosis is obtained by the organization before or at the time of initiation of treatment.”
Documenting the extent to which the patient is aware of their diagnosis(es) and prognosis is not just a requirement—it is a cornerstone of patient-centered care. When done correctly, it:
- Demonstrates that the patient understands their condition and treatment options.
- Ensures the treatment plan aligns with the patient’s goals and preferences.
- Enhances the credibility and validity of the clinical record.
However, many practices struggle with this requirement because:
- It is not routinely articulated in contemporary PT, OT, or Speech Pathology documentation.
- Independent practices often use unique clinical record formats that may not explicitly address this standard.
- Over-reliance on generic "boilerplate" language can undermine the credibility of the documentation.
Let’s look at a statement taken from a recent survey report which used boilerplate language and a pre-written statement:
“Following the evaluation and extensive patient education regarding diagnosis, prognosis, and treatment goals, the patient (parent/guardian, power of attorney holder) actively participated in the creation of the current goals and agrees to the current treatment plan.”
When boilerplate language and pre-written statements are identified in every patient clinical record, it raises questions about whether the statement truly reflects the individual patient’s experience. It may imply that the patient is aware of their diagnosis and prognosis when they are not. Generic language often does not provide sufficient evidence that the patient actively participated in the creation of the current goals or that the patient was involved or agrees with the treatment plan.
The clinician of record is asserting that the patient (or their parent/guardian, power of attorney holder) participated in preparing the POC and agrees to it, thereby implying that the extent to which the patient is aware of the diagnosis(es) and prognosis.
The best practices for documentation and to ensure patient-centered care, consider the following strategies:
1. Personalize the Documentation:- Tailor the language to reflect the unique circumstances of each patient.
- Include specific details about the patient’s condition, goals, and preferences.
2. Document the Conversation:
- Clearly state what was discussed with the patient or their representative (e.g., diagnosis, prognosis, treatment options)
- Note any questions or concerns raised by the patient and how they were addressed.
3. Obtain Explicit Agreement:
- Document that the patient or their representative agrees to the treatment plan
- If applicable, note any modifications made to the plan based on the patient’s input
4. Use Templates Wisely:
- If using templates, ensure they allow for customization and do not rely on generic language
- Train staff to adapt templates to reflect the individual patient’s experience
5. Educate Your Team:
- Provide training on the importance of documenting patient involvement.
- Share examples of compliant and non-compliant documentation.
To help our facilities better understand the intent of the standard 15-D-8, the graphic below outlines the key elements of compliant documentation. This visual aid can be used as a training tool for your team.
Boilerplate language is helpful and can be used as a guide but consider adding a contrasting example of personalized documentation to illustrate best practices. Instead of generic language, consider documenting:
“During today’s visit, the patient expressed a moderate awareness and understanding of their diagnosis of [enter specific condition] and a moderate awareness of their prognosis and expected recovery timeline. They shared personal goals of [enter specific goal], and together we developed a treatment plan that includes [enter specific interventions]. The patient agreed to the plan and expressed no concerns at this time."
We recognize that transitioning to more personalized documentation may require additional time and effort, but the benefits to patient care and compliance are invaluable. Start today by reviewing your current documentation practices and identifying opportunities to incorporate these strategies.
Assessing and documenting the extent to which the patient is aware of the diagnosis(es) and prognosis in the POC is a critical component of high-quality, patient-centered care. While it may require a shift in documentation practices, the effort is well worth it to ensure compliance, enhance credibility, and improve patient outcomes. By understanding the extent to which the patient is aware of their diagnosis(es) and prognosis, healthcare providers can improve communication, foster engagement, and provide the necessary support for better health outcomes.
At QUAD A, we are here to support you in meeting these standards. If you have questions or need further guidance, please do not hesitate to reach out to standards@quada.org.
Since 1980, QUAD A (a non-profit, physician-founded and led global accreditation organization) has worked with thousands of healthcare facilities to standardize and improve the quality of healthcare they provide – believing that patient safety should always come first.
