Chapter 9, 10: Communication Basics, Documentation, and Medical Records Flashcards
how must the PTs and PTAs communicate?
verbal and nonverbal forms of communication
the therapeutic relationship will be highly success if the PT, PTA, and SPTA convey the attitude that they: ?
- value the patient/client
- attentive to the patient/clients needs
- acknowledge the patient/clients message
- genuinely empathize w/ the patient/client
- provide the patient/client w/ the very best care
_____ the ability to imagine oneself in another person’s place and to understand the other person’s feelings, ideas, desires, and actions.
empathy
what are the 3 stages of HCP and patient/client empathy?
- cognitive stage
- the crossing over stage (most significant)
- the coming back to own feelings stage
_____: get into the position of the other persons (listening to pt)
the cognitive stage
_____: for a moment the PTA can feel themselves as the patient.
the crossing over stage (most significant)
_____: comes back to their own person but feels special alliance w/ the patient.
the coming back to own feelings stage
what is the difference of empathy vs. sympathy?
empathy is being able to relate with other through self experiences vs. the ability to understand and support the emotional situation
at all times obtain _________ from the patient for the treatment that is about to be rendered.
verbal informed consent
______: uses messages conveyed orally from a sender to a receiver.
verbal or oral
______: uses messages conveyed through methods other than orally or in writing.
nonverbal
what are the deliveries of communication?
- face to face (best method)
- telephone discussions
- group discussions
- third party discussion (through family member or caregiver)
what should you know about home exercise program handouts (HEP)?
starts the 1st day of treatment and continues till day of discharge, written at the 5th grade level
why do you need to document medical records?
- reimbursement
- assurance quality care
- assurance of continuity of care
- legal reasons
- research and education
- marketing
what is the purpose for documentation for reimbursement?
- provides the basis for coverage decisions by third-party payers
- documentation must describe physical therapy effectiveness
______:
- consistency w/ APTA’s standards of practice
- must be legible and use medically approved abbreviations or symbols
- must be written in black or blue ink; mistake must be crossed out w/ a single line through the error, initialed, and dated by the PTA
APTA Documentation Guidelines
what are the formats for physical therapy documentation?
- POMR
- SOAP
- SOMR
POMR?
problem-oriented medical record
- sections include data, problem list, treatment plan, progress notes, discharge notes
SOAP?
Subjective, Objective, Assessment, Plan
SOMR?
source-oriented medical record
- many hospital charts use SOMR, w/ different sections for physicians, nurses, physical therapy, lab, etc.
What does the SOAP format stand for?
subjective - information provided by the patient
objective - results of tests, measurements, and interventions
assessment - overall response to interventions and the effects of interventions, changes in patient status, and the HCP’s opinion about the patients progress
plan - plan for further diagnostic or therapeutic action or for the next treatment section.
what are the types of physical therapy documentation reports?
- initial evualtion reports (PT)
- daily / weekly notes (PT/PTA)
- progress reports (PT)
- discharge reports/summaries (PT)
______: foundational document for all other reports that follow, through the evaluation the PT establishes the primary purpose for intervention and outlines the expectation for progress
initial evaluation reports
An initial evaluation report may include?
- referral prescription
- physical therapy history
- referral diagnosis
- prior therapy history
______ includes diagnosis, onset date, complications or precautions, frequency/duration
referral / prescription
_____ includes DOB, age, gender, SOC, primary compliant
physical therapy history
_____ includes mechanism of injury; prior diagnostic imaging or testing.
referral diagnosis
what do PTAs write?
daily/weekly treatment notes
what do PTs write?
evaluations, progress reports, and discharge reports
what is evidence-based care/practice?
“entails making decisions about how to promotes health or provide care by integrating the best available evidence w/ practitioner expertise and other resources.”
evidence-based practice needs?
to be documented using researched clinical guidelines and approved PT protocols.
what are the types of computerized documents for medical records?
- electronic medical records (EMR)
- electronic health records (EMR)
what are the benefits of electronic medical documentation?
- submitting info to insurance companies electronically
- monitoring clinician’s productivity
- tracking patients’ visits
- minimizing documentation paperwork
- integrating billing
the physical therapist (PT) establishes the primary purpose for intervention and outlines the expectations for progress in which type of physical therapy documentation report?
initial evaluation report
