*2.PTA 200-Documentation Flashcards
What are 2 models of disability presented in our text?
NAGI and ICF (International Classification of Functioning, Disablility and Health
What are the 4 aspects of Nagi’s model of disability?
Pathology, Impairment, Functional Limitation, and Disability
moving in bed, transferring from one surface to another, rising from a chair, ambulating, dressing, bathing, etc
ADL
community ambulation activities, such as going to the grocery store, bank or restaurant
IADL (I= Instrumental)
refers to the inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment. UNIVERSAL AND RELATES TO PATIENTS ROLE IN SOCIETY
Disability
Any entry into the patient-client record, such as a(n) consultation report, initial examination report, progress note, flow sheet/checklist, that identifies the care/service provided, re-examination, or summation of care.”
Documentation
Of the agencies listed, which ones carry the weight of regulation and legal penalty if not followed?
ICF
what are the reasons we document?
- Create legal documents (ethical and legal responsibility)
- Record patient data- throughout the entire episode of care enabling Outcome Assessment Measures. Example FIM scoring on page 85.
- Record patient care – interventions, turning schedules, response to treatment, etc.
- Provide proof that your care is reasonable and necessary and skilled. (pg 12) Skilled care being of utmost importance.
- Demonstrate the clinical decision making process. PTAs contribute by always relating intervention to POC goals.
- Reimbursement Justification
How many times a particular sequence is repeated
Frequency
How long a particular sequence will take place
Duration
What are the types of documentation?
Narrative, POMR, SOAP, and FOR. Refer to power point for this, she is SUPER confusing. (pages 6,7, and 8) you can edit this if you understand it. lol
Is the PT, PTA or both responsible for the initial evaluation?
PT
Is the PT, PTA or both responsible for the re-evaluation/re-assessment?
PT
Pr
Problem
S
Subjective