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Clinical Practice > Documentation > Flashcards

Documentation Flashcards

1
Q

Why do we document? (5 reasons)

A
  • reimbursement (if you don’t give a reason for something, insurance won’t pay for it)
  • establish the Plan of Care (need to document it, so someone else could do it without you)
  • chart need for services (if you don’t explain the need for care, insurance will cut their funding)
  • justify on-going intervention
  • legal reasons
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2
Q

In one sentence, why do we document?

A

To communicate and tell the story of the patient.

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3
Q

What are the four main types of notes?

A
  1. Initial eval
  2. Treatment notes
  3. Progress notes/re-assessments
  4. Discharge summary
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4
Q

What is an LMN, and what is it for?

A

It is a letter of medical necessity, and it is mainly for equipment justification.

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5
Q

What is the most widely accepted note format? How does it work?

A

The SOAP note format is widely accepted. It is organized and easy to follow. It encourages a sequential approach to clinical decision making. Information is entered in the order of the acronyms initials.

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6
Q

What is the narrative format? Where is it most often used?

A

In the narrative format, the writer develops their own outline of information. It is unstructured, and most often used for pediatrics because they can’t perform some outcome measures. You can’t always describe kids with values, so you have to describe their functionality with your words.

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7
Q

What is the functional outcome report format?

A

This is where you document a pt’s ability to perform. It emphasizes readability by health care personnel not familiar with PT jargon. Often used to explain to the family what happened in a session, so they can understand how the pt is progressing.

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8
Q

Should you document the same way no matter who is reading it?

A

No. You should always consider who the intended reader is. You will document differently whether the family, insurance, PTA, OT or physician is reading it.

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9
Q

What are things that should be done while documenting? (6)

A
  • use abbreviations and correct medical terminology
  • include any information that directly affects what you are currently treating
  • use positive language and focus on ability
  • be objective when describing a patient
  • use templates when they are helpful
  • use person first language
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10
Q

What are things that should NOT be done while documenting?

A
  • omit unnecessary and irrelevant facts
  • do not refer to a person by their disability
  • do not focus on inability
  • avoid labeling a person (like saying “victim of…”)
  • avoid derogatory statements like “patient complains of…”
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11
Q

What are two things to avoid in documentation when trying to be concise?

A
  1. Nondescript terms
  2. Using -ing words. Shorten them by changing the tense.
    (effective documentation pg 58)
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12
Q

Explain the S in a SOAP note.

A

S stands for subjective. Includes:

  • what the pt says about problem or intervention
  • pt’s report of changes in participation or activity limitations
  • pt’s perspective
  • explain the why if you say pt is non-compliant
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13
Q

Explain the O in the SOAP note.

A

Objective. Includes:

  • the therapist’s objective observations
  • describe treatment interventions
  • what is global goal for interventions
  • numbers go here like frequency, duration, and equipment
  • include communication and/or education given to the pt during an intervention
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14
Q

Explain the A in the SOAP note.

A

Assessment. Includes:

  • indication of the progress made towards pt’s goals
  • factors that modify frequency or intensity of intervention
  • modify/set new goals when needed
  • explain why pt needs treatment or equipment
  • give positive and negative responses to treatment
  • what do you want to continue working on
  • your assessment of how pt is doing and what they need
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15
Q

Explain the P in SOAP note.

A

Plan. Includes:

  • how treatment will be developed to reach goals/objectives
  • any specific interventions/treatment for upcoming sessions
  • planned education or interventions for upcoming sessions
  • follow-up
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16
Q

Practice a SOAP note for this Pt:

Pt has had a TKA two weeks ago.

A

Make up an intervention and write a SOAP note.

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17
Q

Sum up the subjective portion in one sentence.

A

What you hear

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18
Q

Sum up the objective portion in one sentence.

A

What you observe and do.

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19
Q

Sum up the assessment portion in one sentence.

A

What you think

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20
Q

Sum up the plan portion in one sentence.

A

What you will do

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21
Q

Does the subjective only include what the patient says?

A

No, it can include any relevant statements or reports made by the family members or caregivers as well.

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22
Q

Whose perception is the subjective portion written from?

A

It includes the patient’s perception of their condition as it relates to rehab progress in everyday activities or quality of life.

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23
Q

What are common pitfalls when documenting the subjective portion?

A
  • Documentation is not specific enough
  • Passing judgement on a patient
  • Including irrelevant information
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24
Q

Where should changes in a patient’s status be documented?

A

In the objective portion

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25
Q

Where are intervention outlines and education documented?

A

In the objective portion

26
Q

What are things to be careful of when documenting the objective portion?

A
  • provided too little detail

- giving a global summary of an intervention

27
Q

Where would you document the Pt saying that his son is concerned?

A

In the subjective portion.

28
Q

Where would you document the Pt performing 10 reps of knee exercises?

A

Objective portion

29
Q

Where would you document the Pt being instructed in proper lifting techniques?

A

Objective portion

30
Q

Where would you document the Pt stating that he hates using his walker?

A

Subjective portion

31
Q

What are some common pitfalls when documenting the assessment?

A
  • Assessment is too vague such as “Pt improving” or “Pt tolerated Rx well”
  • Little insight is provided
  • Instead, describe what pt accomplished in terms of time or endurance or another objective description
32
Q

What are some common pitfalls when documenting the plan?

A
  • the upcoming plan is not indicated

- be specific instead of just saying “continue treatment”

33
Q

What are the basic 6 sections of a standard initial evaluation?

A
  1. Reason for referral
  2. Activities
  3. Systems review/impairments
  4. Assessment
  5. Goals
  6. Plan of care
34
Q

Reason for referral could include…

A

Health condition, social history, and participation

35
Q

Activities could include…

A

Mobility, environment factors, education and or work life

36
Q

System review/impairments could include…

A

Balance, pain, posture, ROM, sensory etc.

37
Q

Assessment could include…

A

Summary including prognosis/diagnosis

38
Q

Goals should be…

A

Functional with time frames

39
Q

Plan of care could include…

A

Coordination/communication, pt instruction, intervention

40
Q

What are three key things to remember when evaluating?

A
  • make sure you are checking for Red Flags and Yellow Flags
  • practice making connections between forms/follow up questions and findings
  • organize what tests (and in what order) you need to run on them as you are gathering information
41
Q

A patient explains their pain. What aspects do you document?

A
  • location
  • quality
  • severity
  • timing
  • factors that make it better/worse
  • setting in which pain occurs
  • associated manifestations
42
Q

What portion of the SOAP note do you document pain in?

A

Pain reports can be located in the subjective and objective portions

43
Q

If you can make the pain go away, is it orthopedic?

A

It might be. If you cannot make the pain go away by changing position, the pain may not be orthopedic.

44
Q

What would you want to find out about a patient’s previous activities?

A

Want to know how their activities are currently impaired. Impaired activities might include walking, dressing, working, or ADLs. You want to find out what you need to work on and what problem specifically affects what activity. This can be a good location for specific outcome measures.

45
Q

What is the difference between activities and impairments?

A

Activities require multiple body parts. Impairments can make activities difficult. They are more specific to a body part. They need to be measurable and specific.

46
Q

What would you include in the assessment portion of an evaluation?

A
  • summary statement
  • rehab diagnosis
  • potential to benefit from physical therapy/justification for intervention
  • this is why I should see them, this is what they would benefit from, this is what we are going to do
47
Q

Differentiate between long term and short term goals.

A

Short term goals should be steps to get to the long term goal.
Long term goals will have different time lines based on the setting. It should be goals for them at discharge. Their long term goals could be close to prior function or it could be different if the injury is severe or their goals are different

48
Q

What are some characteristics of well-written goals?

A
  • goals are outcomes, not processes
  • goals should be concrete, not abstract
  • are measurable and testable
  • goals are predictive
  • goals are determined in collaboration with the patient/family/caregivers
49
Q

What is the formula for documenting goals?

A 
ABCDE
A- actor
B- behavior
C- condition
D- degree
E- expected time
50
Q

Actor

A

Who will accomplish the goal

51
Q

Behavior

A

The action/activity the individual will be able to perform

52
Q

Condition

A

The circumstances under which the behavior is carried out - must include all essential elements of performance

53
Q

Degree

A

The quantitative specification of performance

Ex. degree of assist, time required, distance, time, number of reps

54
Q

Expected Time

A

The time it will take to reach the goal

Ex. within 2 weeks, within 4 therapy sessions, within 2 months

55
Q

How do you make a patient’s goals specific to them?

A

Develop the goals based on a patient’s current level of participation or lifestyle. Make sure you know their prior level of function.

56
Q

What are three important components of goals?

A
  1. objective
  2. patient specific
  3. relate to function
57
Q

Provide another framework for writing goals.

A

Can form goal with this info:

  • who
  • what
  • how much
  • why
  • in order to…
  • as evidenced by…
58
Q

What would you include in the plan of care?

A
  • indicate recommended frequency and duration
  • add communication or coordination with other providers
  • patient-related instruction
  • type of interventions
  • possibly location
  • progress reports: are these goals still appropriate? Are they making progress towards them?
59
Q

What do you do to an error when you are writing in pen?

A

Mark a line through it and initial it

60
Q

How do you sign your name?

A

Credentials and then education.

Ex: Kayla Reimschisel, PT, DPT

61
Q

What are the key legal aspects of documentation?

A
  • legibility
  • dated and timed
  • authentication (signature)
  • noting errors
62
Q

How do you keep information confidential?

A
  • be careful where you store patient documentation. Locked, secure area.
  • keep charts face down so the name is not displayed
  • don’t leave charts unattended
  • do not discuss pt/client cases in open/public areas
  • follow HIPAA requirements

Clinical Practice (19 decks)

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