Documentation Flashcards
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
Types of notes
Initial eval
Daily progress note
Reassess, weekly progress note
Discharge note
Patient/client management note
Exam Eval Diagnosis Prognosis POC
SOAP note
Subjective
Objective
Assessment
Plan
Most daily notes in this format
EXAM - Systems review - impaired or unimpaired
CV/pulm system Integumentary system Musculoskeletal system Neuromuscular system Communication Affect Cognition Learning barriers/education needs
EXAM - Tests and measures
Rule in/out causes of impairment
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
DX (PT)
Discuss rln of Fx deficits to pts impairments or disability
Problem list
Prognosis
Rehab potential
Prediction of level of improvement and time needed to reach this level
Factors influencing it
POC - 3 components
Expected outcomes (long term goals) Anticipated goals (short term goals) Interventions or intervention plan
Expected outcomes
Long term goals of therapy
Generally functional
Based on tests and measures, objective findings
Basis for setting short term goals
Anticipated goals
Short term steps to achieving long term goals
Basis for setting plan
Frequently revised based on how pt is progressing towards LTG
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)
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)
Intervention plan
POC
Interventions pt will receive to reach established goals
Frequency (per day, per week, time frame)
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
