Documentation

Question 1

who is typically the case manager?

Answer 1

nurse or a social worker

Question 2

List duties a case manager typically has

Answer 2

1. screening to ID appropriate pts for case management services
2. planning and coordinating delivery of care by healthcare team
3. making D/C arrangements and following up w/pt
4. evaluating outcomes of care for each pt
5. checking benefits and coordinating w/other benefits
6. recommending insurance policy coverage exceptions where appropriate
7. coordinating referrals to specalists
8. coodinating care w/community services
9. verifying med reasons for employee absences
10. edu workers w/chronic conditions

Question 3

what should PTs communicate to case managers?

Answer 3

1. status and needs of the pt related to our professional eval
2. need to know info to the case manager related to PT needs of the pt

Question 4

when do you begin D/C planning?

Answer 4

Day 1

Question 5

where do you note anticipated D/C plans in the initial eval?

Answer 5

documentated in the POC

Question 6

summarize the purpose of the episode of care summary

Answer 6

to give a big summary of the pt’s outcomes during PT

(essentially a D/C summary)

Question 7

outline the criteria for the conclusion of the episode of care

Answer 7

1. achievement of goals/optimal level of function
2. lack of progress/no longer requires skilled care

Question 8

list the components of the episode of care summary

Answer 8

1. current physical/functional status
2. criteria/justification for termination of PT services in that setting
3. degree of goals/outcomes observed
4. reasons for goals/outcomes not being achieved
5. plans related to the pt or client’s continuing care

Question 9

describe what is include in the following component:

current physical/functional status

Answer 9

1. update the pt’s current functional status to reflect where they are at at the completion of the episode of care

Question 10

describe what is included in the following component:

criteria/justification for termination of PT services

Answer 10

1. provides support for the termination of PT services
   
   • here you relay the results of your reexam and outline your clinical impression of the course of care
   • include a justification as to why skilled care is no longer needed
   • if impairments remain, include justification as to the plan of how the remaining impairments will be addressed

Question 11

describe what is included in the following component:

degree of goals/outcomes met

Answer 11

1. bascially, providing an update on goal achievement status
2. including all goals written througout the course of care (even if goal was achieved by the first reexam)
3. can indicate achievement status with ratio (50% met) or simply with statement of goal met/not met

Question 12

what are some rationale for why goals or projected outcomes were not acheived

Answer 12

1. could be due to:
   
   • an unforeseen change in status
   • a plateau of pt progress
   • continuing PT is no longer feasible
   • skilled PT is no longer needed

Question 13

what should be included in plans related to pt continuing care?

Answer 13

1. HEP
2. referrals for additional services
3. recommendations for follow-up PT care
4. family/caregiver training
5. equipment provided