CH. 2 Documentation Flashcards

1
Q

What is an Evaluation?

A
  • Uses clinical judgement by a physical therapist
  • Synthesize and analyze data collected
  • Identify problems list
    • Body structures or function impairment, activity limitation
  • Referral if needed
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2
Q

What is Intervention?

A

Purposeful interactions between PT and patient to achieve the goals.

  • Therapeutic exercise
  • Training in self-care, ADL
  • Manual therapy

FITT Goals

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3
Q

What are the components of the FITT equation?

A
  • Frequency
    • number of times per week
  • Intensity
    • repetitions (3 sets of 5 reps)
  • Time
    • duration
  • Type
    • specific activity
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4
Q

What is the purpose of Documentation?

A
  • Communication with other professionals
    • organize and coordinate treatment plan
  • Serves as a record of patient care
    • compliance with legal regulations
    • business record
    • reimbursement
  • Research of outcome analysis
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5
Q

4 Types of Documentation:

A
  1. Initial Examination/Evaluation
  2. Visit/Encounter
  3. Re-examination
  4. Discharge/Discontinuation Summary
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6
Q

Components of the Initial Examination/Evaluation:

A
  • Documentation of the initial encounter
  • Include:
    • Examination
    • Evaluation
    • Diagnosis
    • Prognosis/POC
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7
Q

Components of Visit/Encounter:

A
  • Daily note, progress note
  • Written by PT or PTA, each treatment day
  • Document no-show or cancellation
  • Interventions provided, changes related to POC, plan for next session
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8
Q

Components of Re-examination:

A
  • When patient:
    • Has unexpected progress
    • Has not responded to current treatment plan
    • Has new clinical findings
  • Includes data from repeated or new examination elements
  • Modify or redirect intervention
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9
Q

Components of Discharge/Discontinuation Summary:

A
  • Current status
  • Attainment of goals
  • Discharge prognosis
  • Future plans
    • Education
    • Follow-up care
    • Home exercise
    • Home environment
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10
Q

What is the format of Documentation?

A

S.O.A.P. Notes

  • Subjective
  • Objective
  • Assessment
  • Plan
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11
Q

What are the characteristics of Subjective?

A
  • Patient’s self report of status and response to previous treatment(s)
    • History, symptoms, problems, pains
  • Patient’s goals of treatment
  • Results of self-report tests and measures
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12
Q

What are the characteristics of Objective?

A
  • Verifiable data
    • Examination results
  • Objective observations by therapist
    • Determine assistance level
  • Treatment provided
    • Frequency, duration, equipment used
  • Patient response to interventions
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13
Q

What are the characteristics of Assessment?

A
  • Reflect PT’s clinical decision making
  • Problem list, diagnosis, prognosis with justification
  • Summarize the progress toward functional goals
    • Factors affecting progression
    • Modifications of goals or treatment plan
  • Do not document as “treatment tolerated well”
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14
Q

What are the characteristics of Plan?

A
  • Interventions (for upcoming sessions)
  • Changes in intervention strategy
  • Discharge plan
  • Home exercise program
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15
Q

Categorize into S.O.A.P.:

Bilateral UE ROM: WNL

A

Objective

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16
Q

Categorize into S.O.A.P.:

Patient wants to return to work as a farmer

A

Subjective

17
Q

Categorize into S.O.A.P.:

Patient is in need of further home program instruction

A

Assessment

18
Q

Categorize into S.O.A.P.:

therapist will begin training on transfer with a sliding board next session

A

Plan

19
Q

Categorize into S.O.A.P.:

Patient continues to exhibit limitations in caring for assistive equipment

A

Assessment

20
Q

Categorize into S.O.A.P.:

Therapist provided proper body mechanics instruction to patient’s caregiver

A

Objective

21
Q

Categorize into S.O.A.P.:

Patient independently completed self-ROM exercise as instructed

A

Objective

22
Q

Categorize into S.O.A.P.:

Patient will continue with plan of care revised as described

A

Plan

23
Q

What is an example of a Patient-Centered document?

A

Patient walked 200 feet independently.

-DO NOT discuss therapist

24
Q

What is an example of Person-First language in documentation?

A

A patient with stroke

-NOT “a stroke patient”

25
Q

Avoid what when documenting?

A
  • Negative labeling such as: “victim” or “suffer”
  • Subjective judgement such as: “unhealthy”
  • Derogatory statements such as: “complains” and “refuses”
26
Q

Essentials for Documenting:

A
  • Precise and concise
    • without any assistance = independently
    • with therapist nearby = supervision
  • Be specific:
    • Left, Right, Distance
27
Q
A