adequate pt records

Question 1

a PT shall ensure that a patient record meets the following minimum standards. Each entry in the patient record is:

Answer 1

legible, accurately dated, and signed with the name and legal designation of the individual making entry.

understandable, dated, signed by person making entry

Question 2

the pt record contains sufficient info to :

Answer 2

identify the pt on each page of record, justify the interventions, document results of the interventions, indicate advice or cautionary warnings provided to the patient, enable another PT to assume the patients care at any point in the course of interventions, describe the patients medical history

Question 3

for each date of service there is an accurate record of the physical therapy services provided . true or false?

Answer 3

true

Question 4

initial evaluation should have what?

Answer 4

reason for seeking PT, relevant medical diagnoses or conditions, pt signs and symptoms, objective data from measures, PT interpretation of results of exam, clinical rational for intervention, plan of care that includes the proposed therapeutic interventions, measurable goals, and frequency and duration of intervention and patients prognosis

Question 5

therapeutic interventions note should have what?

Answer 5

pts subjective report of the current status or response to intervention, the intervention provided or appropriately supervised, objective data from tests/measures, instructions provided to pt if any, any change in plan of care

Question 6

re-evaluation note when a patient fails to progress as expected, progresses sufficiently to warrant a change in plan of care . True or false ?

Answer 6

true

Question 7

re-evaluation shall have these things in the record or document

Answer 7

pt subjective report of current status or response to visit, assessment of pt findings, pt current functional status, objective data from tests/measures if collected, rationale for continuing ther. interventions and any change in plan of care

Question 8

discharge summary, if care is in an acute care hospital, the entry made under subsection c on the last date that a therapeutic intervention is provided constitutes doc of the conclusion of care if the entry is made by a PT
If care is not provided in an acute care hospital or if a PT does not make the entry under subsection C on the last date that therapeutic intervention is provided, a PT shall make an entry that meets the standards in subsection A in the patient record and document what:

Answer 8

the date on which ther. intervention terminated, the reason that therapeutic terminated, inclusive dates for the episode of care being terminated, the total number of days on which therapeutic intervention was provided during the episode of care, the patients current functional status, the patients progress toward achieving the goals in the plan of care required under subsection B and the recommended plan