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Medical Exercise Professional……

The Job's Not Over Till the Paperwork is Done

 By Michael K. Jones, Ph.D., P.T.

Documentation of medical exercise/post rehab services is becoming more a part of the job descriptions for medical exercise professionals (MXP). This article will clarify the types of reports and documentation MXPs must provide. MXPs are responsible for providing six types of documentation and reports. These include:

  • Introductory Letter
  • Assessment Summary
  • Session Log/Summary
  • Progress Report
  • Discharge Summary
  • Change in Status

These six reports/documents are the foundation of the documentation process in MET. Though time consuming, these reports are vital to the management of clients.

The introductory letter is the first in the sequence of documentation and reports. This letter is sent to the client's referring physician or therapist within 24 hours of the completion of the initial visit. This letter is simply a 1-page letter informing the referral source of the client's first session and requesting notification of any concerns the medical professional may have with the client's participation in a medical exercise/post rehab program.

The assessment summary is just that, a summary of the findings of the assessment and a brief outline of the proposed exercise program. This report is 1-page in length and is forwarded to the referral source within one week of the assessment. Strength, flexibility, function, endurance, stability and pain should be reviewed in this document. One to two sentences will be enough to summarize the findings in each of these areas of the assessment summary.

The session log is summary of the MET session. This is done after each session. This is the most frequently completed of the six types of reports. I highly recommend using a form-based session log rather than a SOAP note. If you are not experienced writing SOAP notes, the use of the session log form may be your best option. Session logs should be completed the day the session occurs.

The progress report is a summary of the progress the client makes in these six areas:

1) Strength

2) Flexibility

3) Function

4) Endurance

5) Pain and

6) Stability

Each area should be summarized in one to two sentences. Recommendations on future exercise programming should be included in the progress report. This report should not exceed one page. The progress report should be completed and forwarded to the medical professional every 30 days or when the client has a follow up medical appointment.

The discharge summary is completed when the client completes the MET program. The areas addressed in both the assessment summary and progress report should be reviewed in the discharge summary. Recommendations on future exercise programming should also be included in the discharge summary. Again, this is a one-page document.

The “change in status” report uses a one-page format to note any significant changes in the client's condition that may warrant intervention on the part of the medical professional. Increased swelling; increased pain and/or loss of function are reasons to communicate a change of status. This report may follow a phone call to the client's physician or therapist if the change in status is significant enough to limit the client's participation in the exercise session. This report reviews the key points made in the phone call to the medical professional.

Documentation will become a bigger part of the job description for all medical exercise professionals. In later posts I will review each type of report in detail as well as providing examples. Join our MedXPRO Network and receive free Medical Exercise Report templates as well as sample letters to medical professionals to use in your practice.

To view a video summary of this article, click here.

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