05-04a: Document Assessment

Question 1

Assessment Section (5)

Answer 1

• Snapshot of patient’s progress toward the goals from the POC
• Summarizes impairment information in the objective section, relates it to skilled intervention (treatment) performed in objective section as well as functional limitations reported in subjective secion
• Shows why skilled care is still medically necessary
• Answers the “so what” about the visit
• Response to treatment, but not generic statements

Question 2

Consultation with other healthcare team members

Answer 2

• Document follow-up information from consultation with other healthcare team members
• Best to discuss with PT, but can be carried out by PTA

Question 3

Plan of Care (POC)

Answer 3

• Course of treatment includes frequency and duration, PT diagnosis, STGs, LTGs/Outcomes, and interventions, activities and education to get there
• Only PT can modify POC

Question 4

Plan Section (PTA)

Answer 4

• PTA documents what he or she will do in the next session or prior to the next session with regards to that patient to progress toward meeting the treatment goals
• Does not include prognosis