Documentation Basics (9/30a) [Integrative Care]

Question 1

Why we document

Answer 1

“If you didn’t document it, it didn’t happen”

Record of patient’s care

Tool for planning/provision of services, communication between providers

Compliance with regulations

Question 2

Audience of documentation

Answer 2

3rd party payers

Physical Therapists

Members of the Medical Team

Managers and Administrators

Researchers

Patients and their families

Question 3

Documentation is required for

Answer 3

Every visit/encounter

Also for no shows and cancellations

Question 4

All documentation must include

Answer 4

Patient identification

PT identification

Components of Pt Management Model (authenticated by PT)

Question 5

Reasons for denial

Answer 5

Poor legibility

Incomplete documentation or no doc for date of service

Too many/unclear abbreviations

Doesn’t demonstrate skilled care or progress

Doesn’t support medical necessity or codings

Repetitious notes

Question 6

SOAP Note - Overview

Answer 6

A practical tool to format note writing

Developed as part of a system for organizing the medical record

Used by many medical and health care providers

Question 7

SOAP - Subjective

Answer 7

Provided by patient, families, caregivers, etc.

EX: pt states he was in a car accident and his car was broadsided on the passenger side

Question 8

SOAP - Objective

Answer 8

Gathered by therapist through observation, tests and measures

EX: strength was 5/5 throughout bilateral upper and lower extremities

Question 9

SOAP - Assessment

Answer 9

Performed by the therapist following completion of the evaluation

Includes

• connections between exam findings
• how impairments relate to functional deficits
• how deficits impact participation
• a movement systems diagnosis

Question 10

SOAP - Plan of Care

Answer 10

The plan for the patient’s treatment

What the patient will receive

Linked to anticipated goals

Question 11

Patient Management Model - Initial Examination/Evaluation

Answer 11

Includes History, Systems Review, Tests and Measures

Question 12

Patient Management Model - History

Answer 12

• General demographics
• Social history
• Employment/work (Job/School/Play)
• Growth and development
• Living environment
• General health status (self-report, family report, caregiver report
• Social/health habits (past and current)
• Family history
• Medical/surgical history
• Current condition(s)/Chief complaint(s)
• Functional status and activity level
• Medications

Question 13

Patient Management Model - Systems Review

Answer 13

Cardiovascular/Pulmonary
- Vital Signs, Edema

Integumentary
- Pliability (texture), Presence of scar formation, Skin color, Skin integrity

Musculoskeletal
- Gross ROM, Gross strength, Gross symmetry and posture

Neuromuscular
- Gross coordination, Quality of movement, Motor control and motor learning

Should also include
- Communication, Affect, Cognition, Learning barriers, Education needs

Question 14

Patient Management Model - Tests and Measures

Answer 14

Selected based upon History and Systems Review

Test and Measure ≇ Outcome Measure

Question 15

Patient Management Model - Evaluation

Answer 15

a thought process that may not include formal documentation

Should lead to documentation of impairments, functional limitations, and disabilities

A problem list (functional vs. impairments)

A statement of assessment of key factors influencing the patient/client status

Question 16

Patient Management Model - Diagnosis

Answer 16

may include impairment and functional limitations

EX: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation

Question 17

Patient Management Model - Prognosis

Answer 17

Documentation of prognosis is typically in the plan of care

Question 18

Patient Management Model - Plan of Care

Answer 18

Overall goals stated in measurable terms that indicate the predicted level of improvement in function

A general statement of interventions to be used

Proposed duration and frequency of service required to reach the goals

Anticipated discharge plan

Question 19

Patient Management Model - Reexamination

Answer 19

Documentation of selected components of examination to update patient’s/client’s impairment, function, and/or disability status

Interpretation of findings and, when indicated, revision of goals

When indicated, revision of plan of care, as directly correlated with goals as documented

Question 20

Patient Management Model - Discharge/Discontinuation Summary

Answer 20

Current physical/functional status

Degree of goals achieved and reasons for any goals not achieved

Discharge/discontinuation plan related to the patient/client’s continuing care

EX: Home program, Referrals for additional services, Equipment provided

Question 21

Documentation of every encounter must include

Answer 21

Pt self report

Identification of interventions (F/I/D)

Changes in impairment

Response to intervention

Factors that modify plan

Communication (providers, pt, family)

Plan for ongoing care

Question 22

Electronic Medical Records (EMR)

Answer 22

Increased interdisciplinary documentation

Use of CPG’s

Increased portability of patient health information (PHI)

Modes will vary between institutions

Confidentiality!!!