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Gen Med > Documentation > Flashcards

Documentation Flashcards

1
Q

Purpose

A

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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2
Q

Types of notes

A

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

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3
Q

Patient/client management note

A 
Exam 
Eval 
Diagnosis
Prognosis 
POC
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4
Q

SOAP note

A

Subjective
Objective
Assessment
Plan

Most daily notes in this format

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5
Q

EXAM - Systems review - impaired or unimpaired

A 
CV/pulm system
Integumentary system 
Musculoskeletal system 
Neuromuscular system
Communication
Affect
Cognition
Learning barriers/education needs
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6
Q

EXAM - Tests and measures

A

Rule in/out causes of impairment

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7
Q

Evaluation

A

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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8
Q

DX (PT)

A

Discuss rln of Fx deficits to pts impairments or disability

Problem list

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9
Q

Prognosis

A

Rehab potential

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

Factors influencing it

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10
Q

POC - 3 components

A 
Expected outcomes (long term goals)
Anticipated goals (short term goals)
Interventions or intervention plan
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11
Q

Expected outcomes

A

Long term goals of therapy

Generally functional

Based on tests and measures, objective findings

Basis for setting short term goals

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12
Q

Anticipated goals

A

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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13
Q

Goals should be

A

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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14
Q

Example of a goal

A

“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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15
Q

Intervention plan

A

POC
Interventions pt will receive to reach established goals

Frequency (per day, per week, time frame)

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16
Q

Intervention plan often includes

A 
-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
17
Q

Soap organizes info

A

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

18
Q

(S) subjective

A

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”
19
Q

(O) objective

A

Observation, systems review, tests, measures

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

20
Q

(A) Assessment

A

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

21
Q

(P) POC

A

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)

22
Q

Daily progress note - Subjective

A

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

23
Q

Daily progress note - objective

A

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

24
Q

Daily progress note - assessment

A

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
25
Q

Daily progress note - POC

A
  • What the PT will do or wants to do
  • Changes in treatment Plan
  • Changes in treatment frequency/duration
  • Changes/revisions of goals
26
Q

Re-assess/weakly/discharge note

A

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

27
Q

Re-assess/weakly/discharge - subjective

A

Updates

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

28
Q

Re-assess/weakly/discharge - objective

A
  • Systems Review – either not mentioned OR summarized

* Tests and Measures – updates pt’s status OR summarizes pt’s condition upon discharge from PT/facility

29
Q

Re-assess/weakly/discharge - assessment

A 
May discuss:
• Any remaining functional limitation
• Whether or not pt achieved STG or LTG
• Suggested further therapy, referral to other health
care professionals
30
Q

Re-assess/weakly/discharge - POC

A

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

31
Q

Accuracy

A

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

32
Q

Brevity

A

Concise
Short, succinct
Approved abbreviations

33
Q

Clarity

A

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

34
Q

All entries should be

A

• 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)

35
Q

Entries

A

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

36
Q

EHR - electronic health record

A

Allows pts, caregivers and others access to patient specific info

37
Q

HIPPA - Health insurance portability and accountability act

A

1996

DHHS establishes national standards for securing electronic health care info

Confidentiality of protected health info

38
Q

Confidentiality

A

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

Gen Med (20 decks)

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