Documentation and Medical Record Flashcards
Why do we need documentation?
reimbursement assurance of quality care assurance of continuity of care legal reasons research and education marketing
Reimbursement documentation
shows:
- PT decision making involved and reasons to do the interventions
- effectiveness of PT treatments
- treatments were cost effective and conducted by skilled practitioner
- THE NEED for Pt to be in PT
quality assurance documentation
define problems outline POC show barriers to recovery tell goals for PT interventions ensure therapist compliance, effectiveness show progress and achievement of goals
continuity of care documentation
describe treatments performed
describe patient response to treatment
modifications to treatments
legal documentation
objective proof of PT care performed
research/education documentation
uses the objective info from documentation to advance the profession
marketing documentation
successful improvements of Pt’s can be a good thing ;)
What does POMR stand for?
problem oriened medical record
What is POMR used for?
data, problem list, treatment plan, progress notes, discharge
helps communication between providers
helps to be better organized
What does SOMR stand for?
source oriented medical record
What is SOAP used for?
to separate sections for physician, nursing, pharmacy, dietary, PT, OT orders, test results etc
read through each section for information
What does SOAP stand for?
Subjective
Objective
Assessment
Plan
The Plan in SOAP?
future diagnostic or therapy or next therapy session
The Subjective in SOAP?
info given by pt or pt family/caregiver “PAIN” is here!!!!
The Objective in SOAP?
results o tests, measres and interventions, objective data
The Assessment in SOAP?
overall response to invterventions and the effects of intervention; changes in the pt’s status, and the provider’s input about the pt’s progress
HPI stands for
History of Present Illness
PMHx
past medical history
PLOF stands for
prior level of functioning
Initial exam and eval contaings…
referral HPI PMHx Med list PT HPI and prior Hx Diagnosis Testing/imaging eval data PLOF Treatment diagnosis assessment including reason for skilled care problems POC
daily/weekly treatment notes
frequency/content dependent on practice setting, the pt type, and the payer involoved
includes pt full name, DOB, MR #, room #
SOAP or narrative
Progress notes involve
notes written by PT’s to provide doc of continuum of care and justification of skilled PT services provided
explanations of the skilled interventions, complicating factors that affect the duration of skilled care
comparative data between initial eval and re-eval
Discharge report
Written by PT to provide the outcome of PT services provided
must include attendance/visits, current objective data, goals and dates goals achieved
Difference between sign and symptoms and where they belong in the SOAP note?
Sign - objective indication of something
(seen, heard, felt or measured)
Objective data
Symptom - a change in the body or its functions perceived by the pt
Subective
Assessment data
summary of data from S&O; patient response to treatment and progress toward goals
