Documentation Flashcards
Clinic purpose of documentation
Communication of interventions provided by PT
Payment objective of documentation
getting paid for services provided
Legal dimension of documentation
professional liability; ensuring interventions were performed purposefully
Why is documentation important?
-form of communication
-fulfills legal requirements for reimbursements
-tool for clinical decision making
-requirement
Minimum documentation required to be done
IE, treatment notes, progress notes, DC notes
Skills needed for reflection
self-awareness, description, critical analysis, synthesis, evaluation
2 essential documentation requirements of the payer when it comes to coding and billing
-doc must show provider services are medically necessary and skilled
-doc must support CPT codes reported on the claim form
6 primary types of info payers are looking for and where they are found in documentation
-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)
Components of appropriate goal (ABCD’s; general)
Audience, behavior, condition, degrees
Describe the A component of appropriate goal
Audience: the who, most often the pt - “pt will demonstrate…”
Describe the B component of appropriate goal
Behavior: what, the behavior or action that IS functional and addresses activities or participation (ex. transfer, ambulate, demonstrate)
Describe the C component of appropriate goal
Condition: under conditions of, circumstances under which the behavior takes place; the specific requirement for the pt to perform the task
Describe the D component of appropriate goal
Degree of the goal: longest component made up by four measures (objective measure of behavior, assistance required, time frame, how goal ties to activities)
What are the 3 areas most dx errors occur with pt-practitioner clinical encounter?
ordering dx tests for further workup, hx taking, exam
What are 3 causes of error in clinical reasoning?
-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
