Documentation Chapter 1-4 Flashcards
Narrative
Paragraph Form, About Patient Encounter
POMR
Patient’s Problems. Problem Oriented Medical Record.
S
Subjective
O
Objective
A
Assessment
P
Plan
Functional Outcomes Reporting
Focus on patient function
Templates & Fill-in Forms
Save time, minimize writing
Electronic medical Record
Computer based documentation
Third Party Payer
Insurance
Reasons for documentation
Patient data, clinical decision making process, proof of skilled care, legal action
Subjective Data, Opinion, Pt. Goals
S
Objective, Measurements, Today’s Treatments, Pt. Education, Observations
O
Assessment, PT Goals, Interpret Data
A
Plans, Future
P
Maintenance Therapy
Not skilled, not physical therapy, not payed by insurance
Health
Free, absent from disease
PTA Treats
What disease is causing?
Disablement
The consequences of disease as they pertain to relationship between body structures, ability to carry out tasks, and ability to function within society.
The Nagi Framework
Functional Limitation - Walk with walkerImpairment - BalancePathology - the disease example Arthritis
Impairments
Deviations from the normal, losses or abnormalities of an anatomical physiological, mental, & emotional nature
Disability
The inability or limitation in performing socially defined roles and tasks that would normally be expected of an individual within a given culture or environment.
ICF - World
International classification of functionFunction - Body tissues structures in tact & functioningDisability - Not in tact & not functioning
ICD-9
Coding for classifying disease, for insurance
Progress Notes
Exercises, Units, Assistance MIA, MOA, MMA, How did pt. do with treatment?
HIPPA
Confidential, Documentation, Sign release forms for people to have access.
Functional Limitiations
Are abnormalities or limitations in an individual’s ability to carry out a meaningful action, task, of activity.
APTA
Votes to endorse the ICF and as a result future APTA publications, documents, and communications will incorporate ICF language
ICD
International Classification of Diseases. Is a classification system for medical diagnoses and diseases.
One of the primary reasons for documenting physical therapy services is to maintain
A record of patient data
Skilled Care
A patient must have a pathology or injury that results in a documented physical or functional limitation and requires a sophisticated and complex intervention that can only be carried about by a licensed PT or a PTA under the supervision of a PT.
SOAP
Has become a stand-alone format for documentation.
Individuals with Disabilities in Education Act (IDEA)
Federal law that governs states to provide a free appropriate public education for all children with disabilities residing in the state between birth to age 21.
IDEA Part C
From birth to age 3, the child is covered under.
IEP
Individualized Education Plan
IEP
Includes the child’s current academic and functional levels, a statement of his or her measurable goals, and services that will be provided. Reviewed annually at minimum.
Physical Therapy School Services
Provided to children in the school system are geared toward enhancing the child’s function in the school in order to meet educational needs. Examples meeting seating, positioning needs, addressing mobility issues in & around the school.
Patient Point of Entry
Individuals’s enter the physical therapy system by self referral or through a referral by another health care practitioner.
Evaluation Process
History taking, system review, tests & measurements, evaluation, diagnosis, prognosis, & plan of care.
Plan of Care Developed
In collaboration with the patient and is based on the examination, evaluation, diagnosis, and prognosis
Properly constructed plan of care
Includes coordination, communication, documentation, patient-related instruction, procedural interventions.
PT Responsibility
Evaluations, re-examination, revision of the plan of care, proper documentation
PTA Responsibility
Interventions selected by the PT in the plan of care, modify details of the treatment program
IFSP Individualized Family Service Plan
It includes the child’s present level of development, family concerns, results of outcome measures, anticipated goals, and kinds of services to be provided.
ICF
Originally known as the International Classification of Impairments, Disabilities and Handicaps
Activities
Functional tasks that the individual can do
Activity limitations
Functional tasks that he or she cannot do
Participation restrictions
Life roles that the individual cannot carry out
Activity and Participation Component
Is one of the biggest difference between the Nagi and ICF
