documentation

Question 1

Based on a functional outcomes, use the ICF model when documenting what?

Answer 1

health conditions, body structure/function, activity limitations, participation

Classifying problems into one of the 4 categories is a critical first step for documentation

Question 2

SOAP note most widely used to organize documentation in what order

Answer 2

Subjective, objective, assessment, plan

Question 3

Documentation in a medical record should be concise, do NOT write a story

Answer 3

Make sure abbreviations are common and able to be understood

Omit unnecessary and irrelevant facts-use knowledge and clinical reasoning to determine what is important

Question 4

when documentation you should use people-first language like

Answer 4

Don’t “paraplegic patient”
Use “patient with paraplegia”
Avoid words such as suffers or victim
Avoid “noncompliant patient” use “patient has not consistently complied with HEP

Question 5

Use of standardized measures are critical to documentation why?

Answer 5

Reliable and valid in a specific population

3rd party payers can dictate use of standardized measures to authorized continued services

Quantify improvements in patient performance and demonstrate value of services to patient and 3rd party payers.

Choosing appropriate and best tests can help and enhance decision making

Question 6

what is the evaluation format

Answer 6

Reason for referral
Activities
Impairments
Assessment
Goals
Plan of Care

Question 7

what are is reason for referral for documentation

Answer 7

Information gathered from medical records and patient interview

Includes information pertaining to health condition, restrictions in participation, and personal/environmental factors

History: getting info from the past and present episodes, identify health restoration and prevention needs and coexisting health problems

What is the health condition that brings that patient to physical therapy

Information gathered is critical for determining how to proceed and for determine whether further referral is indicated

Disease process, location, and time must be gathered

How the condition is affecting the patient’s life

Prior level of function is required by most 3rd party payers and goal is to return to PLOF

Question 8

what are activities

Answer 8

Function is the performance of skills or tasks that are pertinent to his or her daily life

Walking, running, reaching are all parts and elements of functional activities
—-Not activities because they do not have meaningful goal or purpose

Functional activities
-Personal
-Occupational
-Leisure

Therapists must prioritize the functions that are most critical to the patient at the present time.

If only impairments are reported and no activity restrictions, therapists will have trouble justifying need for skilled interventions to 3rd party payers

Standardized tests and measures can be used to assess function

Question 9

what are impairments?

Answer 9

Problems in body structure or function that

Structure and function that is evaluated is based upon activity limitations and health condition

Quantifiable and objective data

ROM, strength, posture, cardio/pulm, communication, cognition, balance, tone

Does included some functional measures: Berg Balance, Glasgow Coma Scale, pain, RPE, Stroke Rehabilitation Assessment or Movement

WNL is used when findings are found to be in typical range. WFL is more ambiguous and should not be used

Question 10

What is the assessment?

Answer 10

Outcome of the clinical decision making process

Structured as a summary statement
-Key problems
-Diagnosis
-Prognosis and potential to benefit from PT

-Avoid abbreviations, clear, unambiguous statements

-State the patient “requires” PT services and avoid “would benefit”

Avoid over generalizing
–“Patient has decreased strength and ROM with is leading to limitations in ADLs” this applies to about 90% of patients

Question 11

what are goals

Answer 11

Intended impact on functioning as a result of implementing a POC

Measurable, functional, and time limited

Measure progress towards an outcome
–Actual result on implementing POC

Collaborative process of the rehab team AND patient/family

Patient centered: focused on what is important and meaningful to the patient

Professional judgment about the patient’s prognosis that is likelihood of functional recovery

Short term goal is an intermediate step to achieving long term goals

—Short term goals require less time frame

Question 12

goals…

Answer 12

Participation goals: specific roles in which the patient wishes to participate

-Provides the “big picture”
-Specific areas of life for participation
-Community, leisure, social activities, and work roles

Question 13

Activity goals: skills necessary to participate in desired roles

Answer 13

-These should always be included in goals
-Walk from room to room, drink from a cup, put on a shirt
-Also termed functional goals

Question 14

Impairment goals: outcome in specific impairments in body function that contribute to the functional limitation

Answer 14

Optional but reasonable type of goal as it is not mandatory as it reflects intervention plan

Important in those who have a serous activity limitation (stroke, SCI) as it may be the only immediate improvement and response to therapy

Should be linked to activity goal

Question 15

write goals in SMART

Answer 15

Specific
Measurable: quantitative
Assignable: Who will complete the task
Realistic
Time bound

Question 16

goals should

Answer 16

-Outcomes not a process
Patient will be taught hip precautions vs patient will verbalize hip precautions

-Concrete NOT abstract
Demonstrate increased control in sitting vs reach to pick up cup

-Measurable and testable:
Good sitting balance vs sit unsupported on the edge of bed 1 min

Question 17

Structure and Formula for writing goals

Answer 17

-Goal = A + B + C + D + E

-A = actor (who will accomplish)

-B = Behavior (task or activity the patient will perform)

-C = Condition (context, circumstances, support)

E = Expected time (time period which the goal will be achieved)

Consider which goals are most important to patient and which ones will achieve the highest level of function when prioritizing

Question 18

example of goals

Answer 18

In 4 weeks, pt will demonstrate a 4 point improvement on the FGA indicating clinically significant positive change in dynamic postural control and reduced fall risk for safer community dwelling.

In 4 weeks, pt will perform a 5XSTS test under standard conditions and in 13 sec or less to demonstrate improved functional strength and power for improved ease performing functional transfers

In 8 weeks, pt will complete 10+ reps of STS during a 30 Second Chair Rise Test indicating improved LE mm. activation and muscular endurance for greater tolerance performing functional transitions.

In 8 weeks, the pt will verbalize performance of an HEP, including daily active exercise, with caregiver assist as needed to reduce disease progression and optimize QOL.

In 8 weeks, patient will improve score by 6 points or greater on the Mini-BESTest indicated improved postural stability and reduced fall risk to reduce the likelihood of developing secondary complications.

Question 19

Plan of Care

Answer 19

-Overall management strategy to accomplish the activity goals

-Includes coordination/communication, patient-related instruction, interventions

-Short and concise

-Includes frequency and duration

Question 20

Daily notes are written for?

Answer 20

Legal documentation
Third-Party payment
Facilitation of outcomes and decision making
Record for other therapists in case of absence

Question 21

SOAP

Answer 21

Subjective: patient’s subjective response, change in limitations/participation

Objective: any objective measurable change in status with regard to activity and impairment. Includes interventions (frequency, intensity, etc)

Assessment: progress being made and progress towards goals, factors that may modify any interventions, modify and add new goals if necessary

Plan: specific plan for upcoming interventions