Documentation Chapter 1-4

Question 1

Narrative

Answer 1

Paragraph Form, About Patient Encounter

Question 2

POMR

Answer 2

Patient’s Problems. Problem Oriented Medical Record.

Question 3

S

Answer 3

Subjective

Question 4

O

Answer 4

Objective

Question 5

A

Answer 5

Assessment

Question 6

P

Answer 6

Plan

Question 7

Functional Outcomes Reporting

Answer 7

Focus on patient function

Question 8

Templates & Fill-in Forms

Answer 8

Save time, minimize writing

Question 9

Electronic medical Record

Answer 9

Computer based documentation

Question 10

Third Party Payer

Answer 10

Insurance

Question 11

Reasons for documentation

Answer 11

Patient data, clinical decision making process, proof of skilled care, legal action

Question 12

Subjective Data, Opinion, Pt. Goals

Answer 12

S

Question 13

Objective, Measurements, Today’s Treatments, Pt. Education, Observations

Answer 13

O

Question 14

Assessment, PT Goals, Interpret Data

Answer 14

A

Question 15

Plans, Future

Answer 15

P

Question 16

Maintenance Therapy

Answer 16

Not skilled, not physical therapy, not payed by insurance

Question 17

Health

Answer 17

Free, absent from disease

Question 18

PTA Treats

Answer 18

What disease is causing?

Question 19

Disablement

Answer 19

The consequences of disease as they pertain to relationship between body structures, ability to carry out tasks, and ability to function within society.

Question 20

The Nagi Framework

Answer 20

Functional Limitation - Walk with walkerImpairment - BalancePathology - the disease example Arthritis

Question 21

Impairments

Answer 21

Deviations from the normal, losses or abnormalities of an anatomical physiological, mental, & emotional nature

Question 22

Disability

Answer 22

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.

Question 23

ICF - World

Answer 23

International classification of functionFunction - Body tissues structures in tact & functioningDisability - Not in tact & not functioning

Question 24

ICD-9

Answer 24

Coding for classifying disease, for insurance

Question 25

Progress Notes

Answer 25

Exercises, Units, Assistance MIA, MOA, MMA, How did pt. do with treatment?

Question 26

HIPPA

Answer 26

Confidential, Documentation, Sign release forms for people to have access.

Question 27

Functional Limitiations

Answer 27

Are abnormalities or limitations in an individual’s ability to carry out a meaningful action, task, of activity.

Question 28

APTA

Answer 28

Votes to endorse the ICF and as a result future APTA publications, documents, and communications will incorporate ICF language

Question 29

ICD

Answer 29

International Classification of Diseases. Is a classification system for medical diagnoses and diseases.

Question 30

One of the primary reasons for documenting physical therapy services is to maintain

Answer 30

A record of patient data

Question 31

Skilled Care

Answer 31

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.

Question 32

SOAP

Answer 32

Has become a stand-alone format for documentation.

Question 33

Individuals with Disabilities in Education Act (IDEA)

Answer 33

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.

Question 34

IDEA Part C

Answer 34

From birth to age 3, the child is covered under.

Question 35

IEP

Answer 35

Individualized Education Plan

Question 36

IEP

Answer 36

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.

Question 37

Physical Therapy School Services

Answer 37

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.

Question 38

Patient Point of Entry

Answer 38

Individuals’s enter the physical therapy system by self referral or through a referral by another health care practitioner.

Question 39

Evaluation Process

Answer 39

History taking, system review, tests & measurements, evaluation, diagnosis, prognosis, & plan of care.

Question 40

Plan of Care Developed

Answer 40

In collaboration with the patient and is based on the examination, evaluation, diagnosis, and prognosis

Question 41

Properly constructed plan of care

Answer 41

Includes coordination, communication, documentation, patient-related instruction, procedural interventions.

Question 42

PT Responsibility

Answer 42

Evaluations, re-examination, revision of the plan of care, proper documentation

Question 43

PTA Responsibility

Answer 43

Interventions selected by the PT in the plan of care, modify details of the treatment program

Question 44

IFSP Individualized Family Service Plan

Answer 44

It includes the child’s present level of development, family concerns, results of outcome measures, anticipated goals, and kinds of services to be provided.

Question 45

ICF

Answer 45

Originally known as the International Classification of Impairments, Disabilities and Handicaps

Question 46

Activities

Answer 46

Functional tasks that the individual can do

Question 47

Activity limitations

Answer 47

Functional tasks that he or she cannot do

Question 48

Participation restrictions

Answer 48

Life roles that the individual cannot carry out

Question 49

Activity and Participation Component

Answer 49

Is one of the biggest difference between the Nagi and ICF