documentation Flashcards
Based on a functional outcomes, use the ICF model when documenting what?
health conditions, body structure/function, activity limitations, participation
Classifying problems into one of the 4 categories is a critical first step for documentation
SOAP note most widely used to organize documentation in what order
Subjective, objective, assessment, plan
Documentation in a medical record should be concise, do NOT write a story
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
when documentation you should use people-first language like
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
Use of standardized measures are critical to documentation why?
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
what is the evaluation format
Reason for referral
Activities
Impairments
Assessment
Goals
Plan of Care
what are is reason for referral for documentation
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
what are activities
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
what are impairments?
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
What is the assessment?
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
what are goals
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
goals…
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
Activity goals: skills necessary to participate in desired roles
-These should always be included in goals
-Walk from room to room, drink from a cup, put on a shirt
-Also termed functional goals
Impairment goals: outcome in specific impairments in body function that contribute to the functional limitation
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
write goals in SMART
Specific
Measurable: quantitative
Assignable: Who will complete the task
Realistic
Time bound
goals should
-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
Structure and Formula for writing goals
-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
example of goals
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.
Plan of Care
-Overall management strategy to accomplish the activity goals
-Includes coordination/communication, patient-related instruction, interventions
-Short and concise
-Includes frequency and duration
Daily notes are written for?
Legal documentation
Third-Party payment
Facilitation of outcomes and decision making
Record for other therapists in case of absence
SOAP
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
