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I am on my Fieldwork IIA, picking up patients for my CI during week 9. I…
I am on my Fieldwork IIA, picking up patients for my CI during week 9. I discovered that there is no evaluation in the chart and no notes have been written for 2 months. My supervisor has asked me to “fill in the documentation” so the facility can bill for these treatments. I don’t even know if the treatments were done but this doesn’t seem right to me.
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Prevention
To prevent a similar situation from occurring, I will work to document immediately after patient care. This will allow me to provide the best information about the therapeutic interventions, the patient's responses, and allow me to be properly anticipating appropriate progress.
To prevent this from happening to others, I will have "accountability partners" for the rehab department so that we can hold each other accountable and strategize to ensure proper documentation.
In my current fielwork setting, every note is to be completed the day of the intervention. This makes it very easy to avoid this ethical dilemma.