Documentation / Billing Flashcards
Purpose of documentation:
- Record what was done
- covering therapist & legal issues
- Organization of thought process
- Reimbursment
- medical necesity & skilled care provided
- Communication
- Tracking pt progress
- research data
- re-evaluation
What do you document?
- PT sessions: everything
- phone calls
- E-mails
- Cancellations
- No-shows
What is considered “documentation?”
- Written reports
- Standardized assessments
- Graphs/tables
- Photos**, videos**, drawings
*Written consent
How do you line out errors in documentation?
with a single line, initial and date
should you cross out any blank lines or spaces in documentation?
yes
What is the SOAP format documentation?
- Subjective: pt report, direct quote, pt perception of his or her condition
- Objective: measurable data. T&M taken, Tx, Instructions given, equip provided, communication.
- Assessment: overall impression, summary of situation, modification of goals. Clarification of inconsistencies bet O and S, justification of continued services.
- Plan: what will you do in the next sessions
In which part of the documentation do you write modification of goals if needed?
A:
In which part of the documentation do you write a summary of the situation?
A:
In which part of the documentation do you write the overall impression of the session?
A:
In which part of the documentation do you write clarification of inconsistencies between Subjective and Objective ?
A:
In which part of the documentation do you write a justification of continued services
A:
In which part of the documentation do you write instructions and communication given to the pt?
O:
In which part of the documentation do you write equipment provided to the pt?
O:
In which part of the documentation do you write changes in the current plan of care?
P:
In which part of the documentation do you write patient’s own perception of his or her condition
S:
