9/30a Documentation Basics (Integrated Care and Practice) Flashcards
why do physical therapists need documentation?
- to justify to insurance companies in writing why someone needs PT services
- Important part of tracking a patient’s progress
- If it wasn’t documented, it didn’t happen!
- If you don’t document, insurance doesn’t reimburse
- Communication with medical team is really through written documentation
- Helpful in legal situations
- CYA COVER YOUR ASS
who are the different professionals that read notes?
-3rd party payers
-Physical Therapists
-Members of the medical team
Surgeons, Doctors, Nurses, OT, ST, Therapeutic Rec, PAS, Social Workers/case management
-managers (audits)
-Administrators (audits)
-researchers
-patients and their families
charting errors
corrected by drawing a single line through the error and initialing and dating the chart or through the appropriate mechanism for electronic documentation that clearly indicates that a change was made without deletion of the original record.
is documentation required for every PT visit?
YES
when to use abbreviations as a PT?
Rarely, make sure that they are used facility wide and they won’t lead to any misunderstanding
Skilled Service language
Services must not only be provided by qualified personnel but they must also require the expertise, knowledge, clinical decision making, and abilities of a physical therapist that others cannot provide.
SOAP Notes
Framework for documentation
-Developed as part of a system for organizing the medical record
-used by many medical and healthcare professionals
S = subjective
O = objective
A = Assessment
P = Plan of Care
Subjective note taking in SOAP
any information from the patient, family members, people providing care (try and make sure it comes directly from the patient)
- Anything about the treatment
- Anything about improvements
- Anything about complaints
- Patient’s goals
- Patient’s lifestyle or home situation
Objective note taking in SOAP
information that you collect as PT through tests, measures, and skilled observation, no self report from patient alone…needs objective measures
- Patient Status
- Intervention
- Modalities Used
- Equipment Used
- Specific enough so anyone can repeat the intervention
- Tests and measures
- No Self Report
Assessment note taking in SOAP
clinical reasoning, synthesis of objective data and subjective information to come up with what we think is impairing the individuals functional mobility/independence
- Thinking about how all of the pieces came together to make a decision
- Performed by the therapist following completion of the evaluation
- Important with ICF, how do these impairments translate to functional ability??
Plan note taking in SOAP
specific info about future services you intend to provide including education for patient, patient family, and caregivers, anything you plan to change from the original
- The plan for the patient’s treatment
- All is linked to anticipated patient goals
Patient Management Model for Note taking
Examination > Evaluation/Referral > Diagnosis & Prognosis > Visit Encounter/Progress Note > Reexamination > Discharge Summary
Note taking in different parts of examination of patient management model
- Patient History
- Systems Review
- Tests and Measures
Patient History
- General Health Status (self report, family report, caregiver report)
- Social/Health habits
- Family history
- Medical/surgical history
- Current conditions/Chief Complaint
- Functional Status and activity level
- Medications
Systems review
- Cardiopulm: vitals, edema
- integumentary: gross range of motion, gross strength, gross symmetry and posture
- MSK: gross coordination, quality of movement, motor control/learning
- Documentation should include: communication, affect, cognition, learning barriers, education needs
tests and measures
selected based on history and systems review
-don’t have to be an outcome measure. Some aren’t as detailed as studies
evaluation
thought process that may not include formal documentation. Should lead to documentation of impairments, functional limitations, and disabilities using formats such as (use of all functions of the ICF)
-problem list should be generated
KEY FACTORS influencing patient/client status
Diagnosis
documentation of a physical therapy diagnosis may include impairment and functional limitations.
**It is critical to understand how the diagnosis impacts the movement system even if it is given to you
Prognosis
documentation of the prognosis is typically included in the plan of care.
Plan of care = general description of how things are going to be addressed
Anticipated discharge plan
Visit encounter progress note
documentation of each visit shall include the following elements
- patient/client self report
- ID of specific interventions provided (frequency, intensity, duration, mode as appropriate)
- Changes in impairment, functional limitation, and disability status
- Response to interventions
- patient/client adherence to instructions
- communication/consultation
- documenting
reexamination
documentation to re-examine the patient’s impairment, function, and/or disability status
discharge/discontinuation summary
stop point at the end of POC, the goals that were reached and those that were not
EMR
electronic medical record
increased portability of patient health information (PHI)
visible to outside institutions
modes will vary
confidentiality
keep patient documentation secure
never leave charts unattended
follow HIPAA
Defensible documentation elements
limit use of abbreviations
date and sign all entries
functional progress toward goals regularly
document time of visit
include all related communications
include missed/cancelled visits
demonstrate discharge planning t/o episode of care
