Documentation Flashcards by Brooke Niles

Purpose

What PT does to manage pt care

Communication w/ other health care professionals

Advocacy for PT/justification for insurance

Quality assurance/ improvement purposes

Outcome research

Education

Compliance

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Types of notes

Initial eval
Daily progress note
Reassess, weekly progress note
Discharge note

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Patient/client management note

Exam 
Eval 
Diagnosis
Prognosis 
POC

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SOAP note

Subjective
Objective
Assessment
Plan

Most daily notes in this format

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EXAM - Systems review - impaired or unimpaired

CV/pulm system
Integumentary system 
Musculoskeletal system 
Neuromuscular system
Communication
Affect
Cognition
Learning barriers/education needs

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EXAM - Tests and measures

Rule in/out causes of impairment

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Evaluation

PT’s professional opinion, evidence of clinical decision-making process

Synthesis and discussion of clinical findings
• Interpret response to tests/measures and integrate with
other information collected in history, Inconsistencies between findings, Further testing needed, Summary of impairments leading to functional limitations, Other factors influencing condition or progress

Justification – for PT decisions, further therapy, referral to
other health care practitioner/services

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DX (PT)

Discuss rln of Fx deficits to pts impairments or disability

Problem list

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Prognosis

Rehab potential

Prediction of level of improvement and time needed to reach this level

Factors influencing it

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POC - 3 components

Expected outcomes (long term goals)
Anticipated goals (short term goals)
Interventions or intervention plan

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Expected outcomes

Long term goals of therapy

Generally functional

Based on tests and measures, objective findings

Basis for setting short term goals

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Anticipated goals

Short term steps to achieving long term goals

Basis for setting plan

Frequently revised based on how pt is progressing towards LTG

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Goals should be

Realistic, measurable, functional, linked to problems ID in exam

Audience (who will exhibit the skill)
Behavior (what person will do )
Condition (circumstances under which the behavior must be done)
Degree (how well behavior will be done - measureable, observable, functional, timeframe)

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Example of a goal

“Pt will amb. with a FWW on level surfaces and curbs x at least 500 ft. x 4 Independently within 3 weeks to allow pt independent mobility at home and in the community”

A: pt (who)
B: will amb (what)
C: with FWW on level surfaces and curbs (condition)
D: at least 500 ft x 4 (measureable)
independently (observable)
within 3 weeks (time frame)
to allow pt I mobility at home/community (functional)

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Intervention plan

POC
Interventions pt will receive to reach established goals

Frequency (per day, per week, time frame)

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Intervention plan often includes

-Location of intervention
• Intervention progression
• Plans for further examination/re-examination
• Plans for discharge
• Plans for pt/family education
• Equipment needed/ordered/dispensed
• Referral to other services
• Patient’s response to interventions

Soap organizes info

According to source.

Subjective
• Examination – history, systems review
• Problem/chief complaint • Objective

Observation, Tests and measures, Systems review

Assessment
• Evaluation, Diagnosis, Prognosis

Plan
• Short term goals, long term goals, intervention plan

(S) subjective

Pt or significant other says:

History 
Systems review 
Current condition/chief complaints (problem) 
Patient’s goals 
Response to treatment interventions 
Other relevant info 
“Quoting verbatim”

(O) objective

Observation, systems review, tests, measures

Comparative data for the future that is
• Observable
• Measurable
• Repeatable

(A) Assessment

• Evaluation
• Diagnosis
• Prognosis
(same as patient/client management format)

(P) POC

3 subsections
• Long term goals – expected outcomes
• Short term goals – steps to achieve long term goals • Interventions or intervention plan
(same as patient/client management format)

Daily progress note - Subjective

Includes updates or additional information regarding pt’s status since most recent note written
• How the pt is feeling
• What the pt says that may relate to medical management
• Additional test results, meds
• Pt complaints
•Pt reported response to treatment interventions

Does not always need to be in a note

Daily progress note - objective

System Review – usually not included unless pt’s
condition changes
• Reporting tests and measures
• What was done during the therapy session

Daily progress note - assessment

evaluation, diagnosis, prognosis
• Commentary on the tests and measures in the Objective section
• How the patient is responding to tx/therapy intervention
• Professional opinion re: pt’s probability of meeting goals or
need for alteration of goals

Recognition of need for:
Changes in tx program
Equipment
Referrals
Recognition of limiting factors
Addition or resolution of problems

Daily progress note - POC

* What the PT will do or wants to do * Changes in treatment Plan * Changes in treatment frequency/duration * Changes/revisions of goals

Re-assess/weakly/discharge note

Update any additional information re: pt’s medical status, test results, etc Summarize medial history, course of treatment • From Initial Eval to Discharge • Since last Re-assessment/Weekly progress note

Re-assess/weakly/discharge - subjective

Updates Summary from initial eval through re-assess/discharge regardless of whether pt feels goals have been met

Re-assess/weakly/discharge - objective

* Systems Review – either not mentioned OR summarized | * Tests and Measures – updates pt’s status OR summarizes pt’s condition upon discharge from PT/facility

Re-assess/weakly/discharge - assessment

``` May discuss: • Any remaining functional limitation • Whether or not pt achieved STG or LTG • Suggested further therapy, referral to other health care professionals ```

Re-assess/weakly/discharge - POC

LTG – indicate which of the Expected Outcomes have been achieved and which have not, why/why not • STG – may or may not comment, depending on facility • Interventions pt received • Pt/family education, and independence with instruction • # of times pt seen in therapy • Mention of pt skipping/canceling • If and when pt not seen or put on hold and why • Reason for discharge • Discharge destination • Recommendations – follow-up, equipment

Accuracy

Medical record is permanent/legal • Typos, grammar, punctuation count • All info should be factual • NEVER: record falsely, exaggerate, guess at, make up data or CHANGE data

Brevity

Concise Short, succinct Approved abbreviations

Clarity

Avoid vague terms Use terminology that is well defined in a given facility Consistent w/in a given facility

All entries should be

• Timely • Legible • Authenticated according to the rules and regulations of the given facility • In compliance with the documentation guidelines of the therapist’s profession • Dated and signed with name and professional designation • Students and graduates pending licensure – authenticated by licensed PT/PTA (co-sign)

Entries

Cannot be deleted or erased Black or blue ink No blank spaces (all blanks on consent forms must be completed) Include referral mechanism

EHR - electronic health record

Allows pts, caregivers and others access to patient specific info

HIPPA - Health insurance portability and accountability act

1996 DHHS establishes national standards for securing electronic health care info Confidentiality of protected health info

Confidentiality

Bound by law and ethical standards to main confidentiality of private health info Cannot be disclosed w/out authorization from pt or as authorized by law or by a court Authorization should be in writing: can be via computer if allowed by state law