documentation Flashcards
PT documentation
- evaluation
- progress notes
- progress summaries/updates
- discharge notes
identifying information
name patient number DOB age address diagnosis
settings
hospital home care skilled nursing facility long term rehab outpatient school system
gathering data: initial exam
- history taking
- review of system
- tests and measures
all help you to gain a clearer picture of the patient’s status and provides a framework for comparisons and clinical decision making
subjective information
proceeding from or taking place within a individual’s mind, perception
- patient’s perception of their problem
- data gathered from patient, family or caregiver
- medical record
objective information
of or having to do with a material object as distinguished from a mental concept
- fact, data
- based on observable phenomenon
- must have measurement reliability and support clinical decisions
- includes data from general systems review and specific tests and measures
- used as a reference point to evaluate progress toward goals
Intervention is also listed here
subjective includes
- patient’s current and PMH
- chief complaint
- factors that impact symptoms/complaints
- prior level of function
- lifestyle/occupation/social roles
- patient’s goals
where are interventions listed?
Objective
where is systems review?
objective
systems review
cardiovascular/pulmonary
neuromuscular
musculoskeletal
integumentary
communication/cognition
objective data includes
ROS ROM MMT aerobic capacity/endurance scales interventions girth
aerobic capacity/endurance measures
taken before AND after
ADL scales distance walked RR, HR, SaO2 step tests auscultation RPE
evaluation
-take info from S and O and evaluate it
= “a dynamic process in which the PT makes clinical judgements based on the data gathered during the examination”
-while examining the patient, develop hypotheses about their clinical problems and gather more data (tests and measures) based on those hypotheses
evaluation/assessment
what do you think about your findings? biased or non-biased? what does the data mean? what will you treat? how will you treat it?
assessment
Typically begins with a narrative interpreting data collected.
contains your clinical impression and must be supported by S and O portions
if PT determines services are not indicated, it should be documented here with suggestions for alternatives- referrals
assessment includes:
- summary of pt status
- PT diagnosis
- relationship between impairment &functional limitation
- need for skilled care
- overview of comorbidities
- positive and negative prognosticators (finances, comorbidities)
- prioritized problem list
- numbered list of LTG, STG
- patient’s potential to benefit from PT
problem list
prioritize
does objective info support subjective and patient complaints?
are there problems outside of the realm of PT practice that need to be addressed? how will you be involved?
writing goals
for every problem identified, there should be a goal and a treatment plan
goals written to address impairment level problems should include clear language to describe how accomplishment will improve function
stated in measurable terms
STGs
steps toward achieving LTGs
usually objective and at the “person level”
ROM, MMT
serve as stepping stones/landmarks to determine progress
useful for 3rd party payers to demonstrate progress being made
can be used to motivate patients in long term rehab situation
must relate to at least 1 LTG
LTGs
final/discharge goals
usually a little more subjective and at the environment/functional level.
functional mobility, endurance
writing behavioral objectives
A= audience (patient) B= behavior (what you expect them to do) C= condition (on level surfaces; on all surfaces) D= degree (how well? 4/5, full ROM) E= expected duration (time frame for accomplishing goal)
OR S=specific M=measurable A=attainable R=realistic T=timely
can revise goals to t/o episode of care
LTG example
within 4 weeks, pt will:
- require min assist X1 for mobility and supine to sit
- increase strength 1 grade throughout to be able to achieve functional goals related to mobility and transfers
STG example
within 2 weeks, pt will:
- require mod assist X1 for bed mobility and supine to sit
- increase strength by 1/2 grade to be able to achieve goals related to bed mobility and transfers
diagnosis and prognosis
practice pattern codes
expected outcomes and duration of treatment
prognosis
=a statement of the predicted optimal level of improvement in function and the amount of time needed to reach that level
can be recorded in form of long-term, discharge or outcome goals
can be adjusted throughout episode of care
factors related to prognosis
Factors related to it include: diagnosis, co-morbidities, general health, surgical and social history, affect, emotional status, etc
plan
includes details of intervention to be provided as well as duration and frequent of proposed episode of care.
written in narrative format
plan includes:
- coordination, communication, documentation
- patient related instructions
- procedural interventions
- time frame for re-evals/re-assessments
- referrals
- discharge or discontinuation
- equipment/resources pt will need on discharge
plan: what will PT consist of?
frequency: how often will you see the pt?
duration: how long will each session be? how long do you expect to treat the patient for?
who will treat the patient?
what interventions will the patient receive?
other team issues and communication: how will they be addressed?
role of the PTA in A and P
PTA reviews the sections of the note written by the PT to get a better understanding of the patient’s situation and goals for treatment
if pt is not responding well to tx as described by PT, PTA will bring this to their attention
interim and discharge notes
- documentation begins with initial note and continues throughout episode of care with daily notes or interim notes
- initial eval, re-eval, and discharge summary are written by PT only
- interim notes should be written by the clinician who provided the service
progress notes
-purpose is to provide a clear statement related to patient’s progress- positive or negative- toward goals and outcomes
includes communication with other providers, PT and other team members
frequency depends on setting:
daily, monthly, quarterly, etc
usually some form of SOAP note
contents of daily note
- subjective reports from patient
- interventions provided
- equipment provided or written instructions to the pt
- pt’s response to tx including objective improvements
- anything that might result in modification of goals/plan of care
- contact with other providers
discharge notes
- final summary of patient progress
- reason for discharge
- PT only
- includes a summary of PT interventions provided and a clear statement of pt’s current status and include data from tests
- should include summary of whether or not goals were met and reasons why if not met
- discharge plans should outline discharge activities such as referral to home care or another PT
documentation generalities
- be prompt
- be specific
- don’t say too little or too much
- be legible
- write so others can understand
- who is your audience?
