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
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
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
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
5
Q
4 Types of Documentation:
A
- Initial Examination/Evaluation
- Visit/Encounter
- Re-examination
- Discharge/Discontinuation Summary
6
Q
Components of the Initial Examination/Evaluation:
A
- Documentation of the initial encounter
- Include:
- Examination
- Evaluation
- Diagnosis
- Prognosis/POC
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
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
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
10
Q
What is the format of Documentation?
A
S.O.A.P. Notes
- Subjective
- Objective
- Assessment
- Plan
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
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
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”
14
Q
What are the characteristics of Plan?
A
- Interventions (for upcoming sessions)
- Changes in intervention strategy
- Discharge plan
- Home exercise program
15
Q
Categorize into S.O.A.P.:
Bilateral UE ROM: WNL
A
Objective