Optimising Documentation Skills for Clinical Justifications

21 June 2017

Documentation skills

Effective documentation is essential to getting great results from therapy, and in helping your clients secure access to the funding and equipment they need to thrive.

With the right documentation in place you can facilitate the success of funding applications that provide vital resources for your clients, and it also helps them meet eligibility criteria for equipment trials that can improve their quality of life.


Clinical Justifications for Funding Applications and Equipment Trials

Some clients may be eligible for funded equipment through other government provisions such as TAC, Workcover or DVA.  This equipment is usually standard type contracted items, however there are exceptions to the rule. Non-contract items can be approved with reasonable justification made by the therapist to emphasise why a particular non-contracted item is necessary. Have they already unsuccessfully trialled contracted items? If so, why did they not suit? Was an alternative option tried, and why was it better?

Additionally, it is important to outline any outcomes and improvements  we can expect if the prescribed equipment is provided for the client. Mention can be made of things like the possible long-term improvements, increased independence, reduced pain, increased pressure care or increased support to facilitate the successful completion of daily tasks, family life or work-related activities.


Funding Applications

When compiling documentation for funding applications it is vital to clearly document the client’s situation and the items already trialled, so the funding body has a comprehensive overview of the  pathway so far. Without complete and thorough documention,  it is difficult for  for the funding body to have an understanding of why particular items are needed as part of a treatment program, and how any funding is justified. These might come under the headings of support, long-term impact, independence and any reduction in carer hours.


Preparing for an Equipment Trial

When preparing documentation in support of an equipment trial there are a number of important inclusions to consider. A description of the client’s condition and other relevant diagnoses (eg dementia) is required, in addition to vital statistics like height, weight and age. Take detailed notes of the client’s house and surrounds – including entry/exit areas and any pets – as these factors will influence any trials. Is the client left or right handed? Do they have any carer requirements or arrangements in place?

Your documentation can make a material difference in the lives of your patients, so you should always strive to be clear, compelling and comprehensive. Effective documentation can be a powerful influence over the outcome of any funding applications or requests for trial equipment.

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