documentation Flashcards
Principles of Note Writing
Accuracy
Brevity
Clarity
Types of Notes
initial note - first visit
daily note
progress note/re-eval - every 10 visits/every 30 or 60 days
Discharge - final visit
Initial Note
Initial Evaluation history system review tests and measure eval plan of care
Accuracy
Do not guess
use correct spelling
initial and date
avoid opinions keep logical
Brevity
utilize chart
abbreviations
clarity
can another therapist understand what you are writing
Daily note
SOAP subjective objective assessment plan
subjective (SOAP)
Pt consent to tx
Pt report of …..
section does not include any type of interpretation of info
objective (SOAP)
result of test/measures
results of objective outcome measures
status up: measurable changes documented
Assessment (SOAP)
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
plan (SOAP)
what are the plans of PT
planned changes to POC
description of what PT wants to do with pt next tx session
outcome measures catagoies
self reported
performance based
self reported
pt/client satisfaction pain QoL condition specific pt specific or client specific
Goal writing
should be in it?
needs to be:
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
coding and billig uses
ICD = international classification of diseases
current version of ICD
ICD 10
does ICD 10 codes have to match diagnosis
No, unless insurance requires
how to choose codes
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
PT diagnosis
what is bringing the patient to PT
Tx Diagnosis
what are you Tx
8 min rule
8-22 min = 1 unit 23-37 = 2 38-52 = 3 53-67 = 4 68-82 = 5
Most PT codes available are in what range
97000 series
payment codes
just because a code exists doesn’t mean a payer will reimburse that code
payment policy is determined by each
Which codes does AMA own
CPT-4 codes
