documentation

Question 1

Principles of Note Writing

Answer 1

Accuracy
Brevity
Clarity

Question 2

Types of Notes

Answer 2

initial note - first visit
daily note
progress note/re-eval - every 10 visits/every 30 or 60 days
Discharge - final visit

Question 3

Initial Note

Answer 3

Initial Evaluation
history
system review
tests and measure
eval
plan of care

Question 4

Accuracy

Answer 4

Do not guess
use correct spelling
initial and date
avoid opinions keep logical

Question 5

Brevity

Answer 5

utilize chart

abbreviations

Question 6

clarity

Answer 6

can another therapist understand what you are writing

Question 7

Daily note

Answer 7

SOAP
subjective
objective
assessment
plan

Question 8

subjective (SOAP)

Answer 8

Pt consent to tx
Pt report of …..
section does not include any type of interpretation of info

Question 9

objective (SOAP)

Answer 9

result of test/measures
results of objective outcome measures
status up: measurable changes documented

Question 10

Assessment (SOAP)

Answer 10

skilled interpretation of info
NO NEW INFO ADDED HERE
most prominent are that the skills of the PT will be demonstrated

analysis of pt:
performance
function

interpretation of changes

Question 11

plan (SOAP)

Answer 11

what are the plans of PT
planned changes to POC
description of what PT wants to do with pt next tx session

Question 12

outcome measures catagoies

Answer 12

self reported

performance based

Question 13

self reported

Answer 13

pt/client satisfaction
pain
QoL
condition specific
pt specific or client specific

Question 14

Goal writing
should be in it?
needs to be:

Answer 14

should be clear

should explain POC

can be used to determine progress, prognosis, conclusion

needs to be:
pt centered
unbiased
objective
quantifiable 
purposeful
time frame

Question 15

coding and billig uses

Answer 15

ICD = international classification of diseases

Question 16

current version of ICD

Answer 16

ICD 10

Question 17

does ICD 10 codes have to match diagnosis

Answer 17

No, unless insurance requires

Question 18

how to choose codes

Answer 18

report specific diagnosis codes supported by the available medical record

in some cases -> unspecified codes are the most accurate

only code to the level you can confirm

Question 19

PT diagnosis

Answer 19

what is bringing the patient to PT

Question 20

Tx Diagnosis

Answer 20

what are you Tx

Question 21

8 min rule

Answer 21

8-22 min = 1 unit
23-37 = 2
38-52 = 3
53-67 = 4
68-82 = 5

Question 22

Most PT codes available are in what range

Answer 22

97000 series

Question 23

payment codes

Answer 23

just because a code exists doesn’t mean a payer will reimburse that code

payment policy is determined by each

Question 24

Which codes does AMA own

Answer 24

CPT-4 codes