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Intro To PT > Chapter 10 > Flashcards

Chapter 10 Flashcards

1
Q

What is documentation considered in PT?

A

-Foundation for communication between third-party payers and providers for PT services.

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2
Q

Why do we need physical therapy documentation?

A

-reimbursement
-assurance of continuity of care
-legal reasons
-research and education
-marketing

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3
Q

what needs to show on document to ensure reimbursement?

A

-that pt services were cost-effective and provided by a skilled practitioner

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4
Q

APTAs documentation guidelines

A

-must be consistent with APTAs standards of practice
-every visit/encounter requires documentation
-documentation must be legible and must use medically approved abbreviations and symbols
-black or blue ink
-electronic health records require security measures
-each intervention must be documented
-informed consents must be signed
-each document must be signed and dated by PTA/PT
-communications with other healthcare providers/professional must be recorded
-documentation of referral occur during initial visit
-cancellations and no shows must be documented

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5
Q

PT students notes should be co- signed by

A

-PT

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6
Q

PTA students notes should be co-signed by

A

-PTs/PTAs

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7
Q

Nonlicensed personnel’s notes should be cosigned by

A

-PT

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8
Q

2 types of medical records

A

1) Problem-orientated medical records
2) Source-orientated medical records

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9
Q

Problem-orientated medical records (POMR)

A

-Introduced in 1970s by Dr. Lawrence Weed
-method of establishing and maintaining the patients medical record so that problems are clearly listed in order of importance, and rational plan for dealing with them is stated.
-DATA IS KEPT IN FRONT OF CHART

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10
Q

Sections of POMR

A

-Data
-Problem list
-Intervention plan
-Progress note
-Discharge notes

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11
Q

POMR enhances…

A

-communication among healthcare providers
-organization and structure of medical info.
-chronological description of interventions
-specific plan to manage patients problems

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12
Q

Source oriented medical records

A

-Arranged in accordance with the medical services offered in the clinical facility.
-some hospitals use SOMRs by labeling a section in the chart for each discipline with a tab marker

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13
Q

1st section of SOMR

A

-physicians section followed by…
-nursing
-pharmacy
-dietary, ETC….

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14
Q

Criticization of SOMR

A

-it is difficult to read through each section for info.

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15
Q

SOAP format

A

-format used to write medical records
-created by Dr. Weed as a component of the POMR.
-each entry contains the date, patients identification number, and title of the patients particular problem, followed by SOAP headings

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16
Q

SOAP headings inlcude

A

-Subjective findings
-Objective findings
-Assessment
-Plan

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17
Q

Subjective findings

A

-about patient and their condition
-symptoms, complaints, goals, lifestyle, difficulties with HEP
-states, reports, says
-patient can be directly quoted

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18
Q

Objective findings

A

-written so reader can reproduce or continue intervention, or someone untrained in PT can see effectiveness of treatment.
-measurements, tests, SIGNS, interventions, observation of interventions, copies of HEP

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19
Q

assessment

A

-summary of objective and subjective part
-most important because it tells reader if PT is working
-included patients response to interventions, progress, or lack of towards goals

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20
Q

plan

A

-future tense
-plan for next section or how many are scheduled
-plan for reeval, introduction to new exercises, future doctor appointments

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21
Q

4 types of documentation reports in physical therapy

A

-initial evaluation report
-visit/encounter treatment notes
-progress reports
-discharge reports

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22
Q

Initial evaluation reports

A

-Foundation for all other reports
-establishes primary purpose for intervention and outlines the expectations for progress
-can be written in SOAP format, narrative, and another format

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23
Q

POMR focuses only on what…

A

-patients impairments and not functional limitations

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24
Q

Functional outcome report

A

-PTs prefer to use this for the initial examination
-includes reason for referral, patients functional limitations, PT assessment, functional outcome goals, and intervention plan.

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25
Q

Why is FOR format becoming popular in PT?

A

-easily demonstrates the effect on impairments on functional limitations and it is relatively uncomplicated for reviewers.

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26
Q

Elements to a initial examination and evaluation report..

A

-referral
-data accompanying referral
-physical therapy history
-referral diagnosis
-prior therapy history
-evaluation data
-prior level of function
-treatment diagnosis
-assessment
-problems
-POC

27
Q

Patient history

A

-part of the initial examination and evaluation
-taken in orderly sequence

28
Q

Elements of patients history

A

-Personal info.
-medical diagnosis
-patients chief complaints
-patients present illness
-onset of patients primary problems
-patients past history
-patients lifestyle

29
Q

Visit/encounter Treatment notes

A

-Written by PTs/PTAs
-typically short
-can be written in SOAP format or narrative (SOAP USED MOST)

30
Q

Treatment notes must include..

A

-patients full name
-date of birth
-medical records number
-room number

31
Q

Focus of progress notes

A

-on the reevaluation of problems identified in the initial evaluation or any new problems developed since last reevaluation

32
Q

Progress notes must include these elements

A

-attendance
-current baseline data
-treatment diagnosis
-assessment
-POC

33
Q

Discharge reports

A

-The last of the four types of reports used in physical therapy.
-written by PT and describe success of physical therapy services

34
Q

What kind of format is used most in physical therapy practice?

A

-SOAP
-can be written daily or weekly

35
Q

The soap format data can be used as follows:

A

-CAN BE WRITTEN BY PT/PTA
1)BY PT TO WRITE THE INITIAL EXAMINATION AND EVALUATION OF REPORTS
-BY PT TO WRITE THE REEXAMINATION AND REEVALUATION PROGRESS REPORT
-BY PT OR PTA TO WRITE THEIR VISIT/ENCOUNTER PROGRESS NOTE.

36
Q

SOAP reexamination and reevaluation report

A

-written by PT periodically throughout the time of the patient is receiving physical therapy.

37
Q

Symptoms

A

-subjective data in SOAP format reports
-a change in the body or its functions perceived by the patient (includes date when symptoms occurred. location, manner in which they occurred).

38
Q

EX of patients symptoms in PT

A

-pain
-stiffness
-weakness
-numbness
-loss of equalibrium

39
Q

As per the Guide to Physical Therapist Practice, physical therapy diagnosis is..

A

-clinical classification by a PT of a patients impairments, functional limitations, and disabilities.

40
Q

What kind of listening does a PTA use to only include relevant info. in the subjective section.

A

-active, directed, attentive, and exploratory listening.

41
Q

Subjective data includes the following..

A

-patients complaints of pain
-patients response to previous intervention
-patients description of functional improvements
-patients life-style situation
-patients goals
-patients compliance or difficulties with HEP.

42
Q

Objective data in SOAP-format notes

A

-info that can be reproduced or confirmed by another healthcare provider with the same training as the one gathering the objective info.

43
Q

Signs as objective data

A

-an objective evidence or a manifestation of an illness or disordered function of body.
-apparent to observers, and symptoms are more apparent to patient/client.
-can be seen, heard, measured, or felt by diagnostician

44
Q

EX of sign in PT

A

-a patients gait pattern such as flexed posture and shuffling gait (PARKISONS DISEASE)

45
Q

Why should the PTA write objective data of progress SOAP note so that…

A

-another PTA may reproduce or continue the intervention or..
-that a reader untrained in physical therapy (lawyer) may determine the effectiveness of treatment session

46
Q

Objective section in progress SOAP note may contain the following..

A

-results of PT measurements and tests
-description of interventions
-description of patients function
-PTAs objective observations of patient during interventions

47
Q

Objective info. of the progress SOAP note must include:

A

-description of the reasons for intervention and intervention provided to patient
-description of the patients response to each intervention
-description of tests/measurements after interventions
-utilization of words that describe the patient performing a function.
-logical organization of information
-utilization of words that portray skilled physical therapy services
-inclusion of copies of additional written info. that was given to patient for home use.

48
Q

Assessment of SOAP format note

A

-represents the summary of the info. from the subjective and objective sections of the SOAP note.
-it tells the reader whether physical therapy is working or not

49
Q

Assessment section contains the following

A

-patients overall response to intervention
-patients progress toward short and long term goals
-explanations as to why the interventions are necessary
-effects of interventions on patients impairments and functional limitations
-comparison of patients abilities from previous date to current one

50
Q

Plan data of SOAP format-notes

A

P=plan
-contains info. that the PTA may need to apply regarding the patients interventions before and during treatment sessions or in between sessions.
-also indicated when next session will be.
-uses verbs in future tense

51
Q

Plan section may include the following

A

-Plan for next treatment session
-plan for consultation with another discipline
-frequency of treatment
-plan for reevaluation or discharge by PT
-Plan to discuss with the PT changes in the patients condition

52
Q

Documentation guidelines should comply with..

A

-jurisdictional requirements
-regulatory requirements
-insurance company requirements

53
Q

general guidelines that apply to physical therapy documentation are as follows:

A

-patients right to privacy
-release of medical info.
-all inquires for medical info. to the PTA should be directed to the supervising PT
-written physical therapy records should be kept in a safe and secure place for 7 years.

54
Q

When PTA verbally takes a telephone referral from another healthcare provider, the PTA needs to document in writing the following:

A

-date and time of phone call
-name of person calling and name of healthcare provider who referred the patient
-name of PTA who took the referral
-date of when a written copy of the referral will be sent to PT office
-name of PT who will be responsible for referred patient.

55
Q

APTA recognizes the following preferred order

A

-PT/PTA
-highest earned physical therapy-related degree
-other earned academic degree
-specialist certification credentials in alphabetical order
-other credentials external to APTA
-other certification or professional honors

56
Q

Physical therapist professional education

A

-refer to the basic education of the PT to qualify him or her to practice physical therapy

57
Q

physical therapist post-professional education

A

refer to the advanced physical therapy educational studies undertaken by a PT to enhance his or her professional skills/knowledge.

58
Q

Defensible documentation

A

-intrinsic part of pt clinical practice
-integrates latest evidence into practice

59
Q

defensible documentation should include

A

-reflects PTs decision-making process
-indicates evidence of the PTS unique body of knowledge and skill
-provides the PTs verification of his or her judgment

60
Q

APTA recommendation tips for documentation that reflects evidence-based care

A

-PTs should incorporate valid and reliable tests and measures
-PTs and PTAs should keep up to date with current research
-PTs should include standardized tests and measures in clinical documentation
-PTs and PTAs should review and incorporate evidence-based interventions into clinical physical therapy.

61
Q

computerized documentation

A

-rapidly becoming the norm
-allows for point of service documentation

62
Q

point of service documentation

A

-requires the PT/PTA to be adept at communicating with and attending to the patient while documenting patients responses, collecting objective data, monitoring exercise, or assessing progress.

63
Q

benefits of computerized documentation

A

-submitting info. to insurance companies
-monitoring clinicians productivity
-tracking patients visits
-easing patient scheduling
-minimizing documentation paperwork
-integrating billing
-maximizing efficiency
-increasing reimbursement
-improved communication between healthcare teams

Intro To PT (25 decks)

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