documentation

Question 1

PT documentation

Answer 1

• evaluation
• progress notes
• progress summaries/updates
• discharge notes

Question 2

identifying information

Answer 2

name
patient number
DOB
age
address
diagnosis

Question 3

settings

Answer 3

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

Question 4

gathering data: initial exam

Answer 4

• 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

Question 5

subjective information

Answer 5

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

Question 6

objective information

Answer 6

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

Question 7

subjective includes

Answer 7

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

Question 8

where are interventions listed?

Answer 8

Objective

Question 9

where is systems review?

Answer 9

objective

Question 10

systems review

Answer 10

cardiovascular/pulmonary

neuromuscular

musculoskeletal

integumentary

communication/cognition

Question 11

objective data includes

Answer 11

ROS
ROM
MMT
aerobic capacity/endurance scales
interventions
girth

Question 12

aerobic capacity/endurance measures

Answer 12

taken before AND after

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

Question 13

evaluation

Answer 13

-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

Question 14

evaluation/assessment

Answer 14

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?

Question 15

assessment

Answer 15

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

Question 16

assessment includes:

Answer 16

• 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

Question 17

problem list

Answer 17

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?

Question 18

writing goals

Answer 18

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

Question 19

STGs

Answer 19

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

Question 20

LTGs

Answer 20

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

Question 21

writing behavioral objectives

Answer 21

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

Question 22

LTG example

Answer 22

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

Question 23

STG example

Answer 23

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

Question 24

diagnosis and prognosis

Answer 24

practice pattern codes

expected outcomes and duration of treatment

Question 25

prognosis

Answer 25

=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

Question 26

factors related to prognosis

Answer 26

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

Question 27

plan

Answer 27

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

Question 28

plan includes:

Answer 28

- 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

Question 29

plan: what will PT consist of?

Answer 29

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?

Question 30

role of the PTA in A and P

Answer 30

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

Question 31

interim and discharge notes

Answer 31

- 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

Question 32

progress notes

Answer 32

-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

Question 33

contents of daily note

Answer 33

- 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

Question 34

discharge notes

Answer 34

- 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

Question 35

documentation generalities

Answer 35

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