Documentation Basics (9/30a) [Integrative Care] Flashcards
Why we document
“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
Audience of documentation
3rd party payers
Physical Therapists
Members of the Medical Team
Managers and Administrators
Researchers
Patients and their families
Documentation is required for
Every visit/encounter
Also for no shows and cancellations
All documentation must include
Patient identification
PT identification
Components of Pt Management Model (authenticated by PT)
Reasons for denial
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
SOAP Note - Overview
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
SOAP - Subjective
Provided by patient, families, caregivers, etc.
EX: pt states he was in a car accident and his car was broadsided on the passenger side
SOAP - Objective
Gathered by therapist through observation, tests and measures
EX: strength was 5/5 throughout bilateral upper and lower extremities
SOAP - Assessment
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
SOAP - Plan of Care
The plan for the patient’s treatment
What the patient will receive
Linked to anticipated goals
Patient Management Model - Initial Examination/Evaluation
Includes History, Systems Review, Tests and Measures
Patient Management Model - History
- 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
Patient Management Model - Systems Review
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
Patient Management Model - Tests and Measures
Selected based upon History and Systems Review
Test and Measure ≇ Outcome Measure
Patient Management Model - Evaluation
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
Patient Management Model - Diagnosis
may include impairment and functional limitations
EX: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation
Patient Management Model - Prognosis
Documentation of prognosis is typically in the plan of care
Patient Management Model - Plan of Care
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
Patient Management Model - Reexamination
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
Patient Management Model - Discharge/Discontinuation Summary
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
Documentation of every encounter must include
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
Electronic Medical Records (EMR)
Increased interdisciplinary documentation
Use of CPG’s
Increased portability of patient health information (PHI)
Modes will vary between institutions
Confidentiality!!!
