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Basic eval 2 > documentation > Flashcards

documentation Flashcards

1
Q

PT documentation

A
  • evaluation
  • progress notes
  • progress summaries/updates
  • discharge notes
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2
Q

identifying information

A 
name
patient number
DOB
age
address
diagnosis
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3
Q

settings

A 
hospital
home care
skilled nursing facility
long term rehab
outpatient
school system
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4
Q

gathering data: initial exam

A
  • 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

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5
Q

subjective information

A

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
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6
Q

objective information

A

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

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7
Q

subjective includes

A
  • patient’s current and PMH
  • chief complaint
  • factors that impact symptoms/complaints
  • prior level of function
  • lifestyle/occupation/social roles
  • patient’s goals
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8
Q

where are interventions listed?

A

Objective

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9
Q

where is systems review?

A

objective

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10
Q

systems review

A

cardiovascular/pulmonary

neuromuscular

musculoskeletal

integumentary

communication/cognition

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11
Q

objective data includes

A 
ROS
ROM
MMT
aerobic capacity/endurance scales
interventions
girth
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12
Q

aerobic capacity/endurance measures

A

taken before AND after

ADL scales
distance walked
RR, HR, SaO2
step tests
auscultation
RPE
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13
Q

evaluation

A

-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

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14
Q

evaluation/assessment

A 
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?
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15
Q

assessment

A

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

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16
Q

assessment includes:

A
  • 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
17
Q

problem list

A

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?

18
Q

writing goals

A

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

19
Q

STGs

A

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

20
Q

LTGs

A

final/discharge goals
usually a little more subjective and at the environment/functional level.
functional mobility, endurance

21
Q

writing behavioral objectives

A 
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

22
Q

LTG example

A

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
23
Q

STG example

A

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
24
Q

diagnosis and prognosis

A

practice pattern codes

expected outcomes and duration of treatment

25
Q

prognosis

A

=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

26
Q

factors related to prognosis

A

Factors related to it include: diagnosis, co-morbidities, general health, surgical and social history, affect, emotional status, etc

27
Q

plan

A

includes details of intervention to be provided as well as duration and frequent of proposed episode of care.

written in narrative format

28
Q

plan includes:

A
  • 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
29
Q

plan: what will PT consist of?

A

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?

30
Q

role of the PTA in A and P

A

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

31
Q

interim and discharge notes

A
  • 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
32
Q

progress notes

A

-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

33
Q

contents of daily note

A
  • 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
34
Q

discharge notes

A
  • 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
35
Q

documentation generalities

A
  • be prompt
  • be specific
  • don’t say too little or too much
  • be legible
  • write so others can understand
  • who is your audience?

Basic eval 2 (5 decks)

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