Wondering what your ABC surveyor expects to see in your patient records? The PR.6 standards and their accompanying tips found in the Standards Guide provide the most concise list of what should be included. Think of building proper patient records the same way you would constructing a building. Follow along as we lay the groundwork for good documentation.

PR.6 – The Foundation

Before you even get started, you will need to establish a foundation for your documentation with a written policy that your patient records include the following:

• Written, pictorial or documented oral instructions related to the use, maintenance, cleaning, infection control practices for and potential hazards of equipment and/or items

• Verification that the equipment, items and services were received

• The make and model number of any non-custom equipment and/or items provided

This documentation ensures that we not only know what item(s) the patient received, but that they have been given the necessary information needed to use and maintain the items.

PR.6.1 – The Support

No building can stand strong without good support. Crucial details like those found in the prescription, patient history, pre-treatment and current treatment documentation are what back up your plans moving forward. As such, it’s important that your patient records include:

1. Patient evaluation/assessment that contains diagnosis, prescription or valid order, relevant patient history and medical necessity

2. Pre-treatment photographic documentation as appropriate for the item

3. Patient education

4. The name and title of the patient care provider, their findings, recommendations, treatment plan and follow-up schedule

PR.6.1.1 – The Structure

Finally, it’s time to give your building some structure. When deciding what materials to use, you should consider current and previous conditions, the tools that are available and the overall goals for the project. Documenting your patient’s need for a device includes many of those same considerations. PR.6.1.1 requires that your patient records document the patient’s need for and use of the orthosis, prosthesis and/or pedorthic device, including, but not limited to:

1. Pertinent medical history

2. Allergies to materials

3. Skin condition

4. Diagnosis

5. Previous use of orthoses, prostheses and/or pedorthic devices

6. Results of diagnostic evaluations

7. Patient goals and expectations