Documentation Flashcards
SOAP
Subjective
Objective
Assessment
Plan of Care
Subjective
Primary complaint
Activity and participation as identified by the patient
Reason for referral
Objective
Qualitative and Quantitative
ROM, MMT, quality of movement, pain ratings
Innerventions
Assessment
Impairment based diagnosis
Interpretation and summary of findings
Reports the need for skilled physical therapy intervention
Goals and prognosis
Plan of Care
How often you will see them
What the patient will be doing
When a reassessment will reoccur
Communication of Care
Education
PT Interventions
Goal of intervention
Impairment goals
Activity goals
Participation goals
Goal of Prognosis
Timeline
ID contextual factors
Likelihood of acheiving goals of caree
What is the purpose of documentation?
- Communitation tool for continuity of care (What exercises are they doing?, what are their symptoms like?, etc.)
- Clinical Decision Making
- Explain rationale for treatment
- Justify Skilled Care (PT vs others ex: OT)
Types of Documentation
- Initial Evaluation
- Session Note
- Re-evaluation or progress note
- Re-evalutation without a scheduled follow up appt (discharge)
Initial Evaluation
- Required at the onset
- Written by the PT
- Reason for Referral: Health Condition
- Goals of Intervention
- SOAP
Session Note
- Written by a PT OR PTA
- SOAP
Progress Note
- Written by PT
- SOAP
- Updates on impairments and activities
- Reexamination
Progress note without a scheduled follow up (discharge)
- Written by PT
- SOAP
- Recommendation for home exercise program
- Plan to follow up with patient (You call to follow up or they call and update)
Hand Written Documentation Requirements
- Must be black and blue ink
- Write legibly (Can be denied if not)
- Legal Doc must be able to defend what your write
Two ways to document medical necessity
- Document functional regression has occurred (Ex: Knee Surgery)
- Document that without skille dintervention function will decline (Ex: Parkinsons)
What makes PT “Skilled”
- We focus on activation, motion, etc.
Patient Specific Functional Scale (PSFS)
- Self-reported, patient-specific outcome measure, designed to assess fucntional change
- Patient picks 3-7 areas of function
- Rate 1-10 scale and socre is added (1= unables and 10 = goal function)
- Easy to incorporate during initial evaluation and can be used as a functional outcome measure
Payment and Coding include what two things?
Diagnosis - ICD-10 - Why they come to PT
Time spent with patient - CPT - Reimbursement
What is it called when you go back and modify a note?
Addendum
Audit
Detailed review of clinical records for evaluating quality of medical care
Authentications
Identification of the author of the medical record and confirmation the contents are what the author intended
Notice of Privacy Practicies (NPP)
Written document given to a health care consumer to explain privacy policies related to medical records
Third-party payer
An org other than patient or health care provider that pays the bill
Informed Consent
- Education of assessment or intervention
- Risk/Benefits
- Person has appropriate reasoning abilities
- Offer to awnser questions
If a mishap occurs what do you do? (3)
- Document what lead to incident
- Response to incident
- Follow up with patient
Recipe for an Assessment (4)
- Summary/Introductory Statement
- Diagnosis Statement
- Need for Skilled Physical Therapy Services
- Prognosis Statement
Summary/Introductory Statement
- Patient age and any other descriptors necessary
- Updated diagnosis/health condition and onset of symptoms
- Pertinent Medical hostpry and OTHER health conditions that may effect PT care
Diagnosis Statement
- Alternate to reffering dx and rationale - if needed
- Sentence or bullet structure impairments
- how impairments affect activity and participation restrictions
Prognosis Statement
- ID contextual factors that may predict a favorable or not so favorable outcome of PT
- What is the likelihood the patient will acheiev the goals of care
