Doccumentation/Communication (wk 2)

Question 1

What is the predicted optimal level of improvement in function and amount of time needed to reach that level established after the diagnosis is determined?

Answer 1

Prognosis

Question 2

What information must be included in your prognosis?

Answer 2

1. Predicted optimal level of improvement in function
2. Amount of time needed to reach that level
3. May include a prediction of levels of improvement that may be reached at various intervals during the course of therapy
4. Must also include a discussion of factors likely to influence prognosis to justify your reasoning for determining the prognosis.

Question 3

What are some prognostic considerations?

Answer 3

a. Severity
b. Complexity
c. Acuity of pathology or
d. pathophysiology
e. Impairments in body function and structures
f. Activity Limitations
g. Participation Restrictions

Question 4

What are factors that can influence prognosis?

Answer 4

a. Age
b. Motivation/Patient compliance
c. Prior activity level
d. Home support
e. Cognitive/mental status
f. Comorbidities
g. Anatomical changes secondary to dysfunction
h. Health status
i. Psychosocial and socioeconomic factors
j. Availability to resources
k. Acute vs Chronic problem
l. Concomitant conditions
m. Severity of the current condition/level of impairment

Question 5

Where is the prognosis documented in the initial evaluation?

Answer 5

Plan of care or assessment

Question 6

Important to make explicit statement regarding the patient’s capacity to improve to the level you have designated as their predicted optimal level of function using what possibilties?

Answer 6

excellent, good, fair, poor

• > include details why making this judgement
• > discussion of factors influencing prognosis

Question 7

Why is prognosis and the details of why important?

Answer 7

important because it supports or justifies the need for skilled physical therapy (living conditions, ability to make it to therapy, prior level of activity)

Question 8

When stating that the patient has a “fair” or “poor” prognosis or rehabilitation potential, how may that be interpreted by the payer?

Answer 8

as the patient not being appropriate to receive physical therapy services

Question 9

T/F Can justify skilled care from the standpoint of equipment needs and family education training

Answer 9

True

Question 10

What are of documentation specifies the general interventions to be used and anticipated frequency and duration of physical therapy visits?

Answer 10

POC

Question 11

What are the components of the POC?

Answer 11

1. Specific goals
2. Predicted level of optimal improvement/anticipated discharge plans
3. General interventions to be used (therapeutic exercise, manual therapy…)
4. Proposed duration and frequency (outpatient: 2x a week/8 weeks)
   - Can re-access with justification

Question 12

What model can you use for goal writing

Answer 12

IFC model - link impairments to activity/function

Question 13

What must a goal include?

Answer 13

1. patient-centered
2. objective (not a range)
3. measurable
4. functional
5. include a time element for achieving the goal

Question 14

In the anticipated discharge plans, list coordination with any other care members:

Answer 14

i. Recommendations for transitioning to an alternative setting at DC
ii. Coordination with other team members required for pt education (or family)

Question 15

Describe how to indicate interventions to be used:

Answer 15

1. Broad
2. must be measurable outcome
3. how to be delivered ( PT, PTA…)

Question 16

T/F Implementing interventions based solely on an intervention protocol or by diagnosis goes against the ICF model and is not representative of patient-centered care

Answer 16

True

Question 17

The proposed frequency and duration you see a patient can be determined by what 4 things?

Answer 17

a. Setting you practice in
b. Capacity of your patient to participate in the POC
c. Patient transportation needs
d. Limitations mandated by 3rd party payers

Question 18

T/F Assessment of the patient’s response to treatment only occurs on the first encounter.

Answer 18

False, Assessment of the patient’s response to treatment must occur at every patient encounter

Question 19

In order to modify the POC what must be performed?

Answer 19

Reevaluation

Question 20

T/F Alterations to POC only reliant on if patient gets better.

Answer 20

False, dependent on all 3:

a. Patient’s function has diminished
b. Patient’s function has not changed
c. Patient’s function has improved

Question 21

What is performed to evaluate progress and to modify or redirect intervention?

Answer 21

Reexamination

Question 22

Reasons to perform a Reexamination (3):

Answer 22

1. Unanticipated change in the patient’s status
2. failure to respond to PT intervention as expected
3. The need for a new POC and/or time factors based on state practice act or other requirements (ie payer requirements)

Question 23

What are 4 components of reexamination?

Answer 23

1. Clinical impression/diagnosis - changes in patient or status
2. Objective reassessment of tests and measures and outcome tools (add new ones)
3. Goal status - addition or revision
4. Evaluation - prognostic status, updated freq/duration, why skilled intervention recommended, transition to next level of care

Question 24

What does SBAR stand for?

Answer 24

Situation - immediate problem/situation
Background - relevant background to the issue/problem
Assessment - conclusions about the present situation
Recommendation - done to correct the problem