Documentation Flashcards

1
Q

Clinic purpose of documentation

A

Communication of interventions provided by PT

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2
Q

Payment objective of documentation

A

getting paid for services provided

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3
Q

Legal dimension of documentation

A

professional liability; ensuring interventions were performed purposefully

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4
Q

Why is documentation important?

A

-form of communication
-fulfills legal requirements for reimbursements
-tool for clinical decision making
-requirement

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5
Q

Minimum documentation required to be done

A

IE, treatment notes, progress notes, DC notes

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6
Q

Skills needed for reflection

A

self-awareness, description, critical analysis, synthesis, evaluation

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7
Q

2 essential documentation requirements of the payer when it comes to coding and billing

A

-doc must show provider services are medically necessary and skilled
-doc must support CPT codes reported on the claim form

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8
Q

6 primary types of info payers are looking for and where they are found in documentation

A

-what’s wrong w/ pt (exam and eval)
-what’s planned for pt (POC, goals, and prognosis)
-what skilled care was delivered by PT/PTA? Specific services? (daily notes and/or progress reports and reevals)
-what was outcome of delivered service?
-what was pt status and prognosis at DC? (DC summary)

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9
Q

Components of appropriate goal (ABCD’s; general)

A

Audience, behavior, condition, degrees

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10
Q

Describe the A component of appropriate goal

A

Audience: the who, most often the pt - “pt will demonstrate…”

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11
Q

Describe the B component of appropriate goal

A

Behavior: what, the behavior or action that IS functional and addresses activities or participation (ex. transfer, ambulate, demonstrate)

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12
Q

Describe the C component of appropriate goal

A

Condition: under conditions of, circumstances under which the behavior takes place; the specific requirement for the pt to perform the task

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13
Q

Describe the D component of appropriate goal

A

Degree of the goal: longest component made up by four measures (objective measure of behavior, assistance required, time frame, how goal ties to activities)

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14
Q

What are the 3 areas most dx errors occur with pt-practitioner clinical encounter?

A

ordering dx tests for further workup, hx taking, exam

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15
Q

What are 3 causes of error in clinical reasoning?

A

-failure to filter and group s/s into meaningful and manageable chunks of info
-letting biases cloud reasoning
-ineffectively gathering pertinent info to guide clinical reasoning

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16
Q

Characteristics of clinical reasoning

A

cognitive and interactive
mostly unobservable
automatic and subconscious
multifactorial and context-dependent

17
Q

What does clinical reasoning consist of?

A

-data gathering, organization, interpretation
-hypothesis generation and testing
-critical eval of alternative dx and tx strategies

18
Q

How is the skill of clinical reasoning enhanced?

A

practice

19
Q

Brief description of Maitland system of clinical reasoning

A
  1. pt profile, c/c, body chart
  2. formulate initial hypotheses
  3. agg/ease; 24 hr, past hx, present hx, ROS, pt goals, outcome measures
  4. reprioritize and refine hypotheses
  5. ROM, manual exam
  6. intervention matched to se/oe, test/retest, prognosis
  7. follow up appt
  8. refine hypotheses w/ continuous assessment
20
Q

Different types of electronic health records/documentation

A

-EHR, EMR
-Epic (used by most hospitals)
-Cerner
-eRehabdata
-WebPT (common among PT clinics)