Documentation Chapters 1-3 Flashcards
Disablement
The consequences that chronic or acute conditions have on the body and the person’s ability to act in a socially expected and personally desired way.
Functioning
Umbrella Term, Includes all body functions, activities, and limitations.
Positive Ascpect
Disability
Umbrella Term, Dysfunction at one or more impairments, activity limitation, and participation restriction
Negative aspect
Body Functions
physiology of the body and psychological functions
(how everything works together)
Body Structures
anatomy of body
(all the physical parts and pieces)
Impairments
problems with body functions or structures
Activity
functional tasks a person can do
Activity Limitations
functional tasks a person CAN NOT do
Participation
life roles a person can participate in
Participation Restrictions
life roles a person CAN NOT participate in
Contextual Factors
Factors that make up a person’s life, living, and background
Environmental Factors
Physical, social, and attitudes the person lives and carries out their lives in
Like home, work, government, and country
Personal Factors
Specific to the person and their background.
Like age, gender, race, childhood, and coping strategies.
Difference between impairment, activity limitation, and participation restriction.
Impairment is a problem in the body’s function or structure like limited ROM.
Activity limitation is a task the person can not complete like brushing their hair.
Participation restriction is a life event a person can not take part in like the ability to work.
Documentation
Any entry into the individual’s health record like consultation reports, initial examination reports, progress notes, summations of care, etc. that identifies the care the person received and their response to that care.
Why is there a need for a common language in PT documentation?
If there was no common language in PT documentation there would be no common ground from specialty to specialty causing miscommunication between reimbursors and other health care providers. It would also be hard to read and apply EBPs to treatment.
How can disablement concepts be integrated into PT documentation?
A PTA can incorporate disablement concepts into their documentation by including measures of impairments, limitations, or restrictions and describing how the impairment is involved in such limitations and restrictions. The PTA should also explain how the interventions are bringing change to the impairment, limitations, and restrictions.
Examples of Participation restrictions
Going to school
Walking in the community
Going to the grocery store
Working
Examples of Activity limitations
Taking a bath
Brushing teeth
Going up and down stairs
Turning a doorknob
Writing
Donning socks
Examples of impairments
Limited ROM
Poor endurance
Poor balance
How can a pt. access a PT for care
Patients can access physical therapy care by self-referral (depending on insurance and state regulations), referral from other health care professionals, hospitalization, home health services, and school-based services.
6 Elements of Patient/Client Management Model
- Examination
- Evaluation
- Diagnosis
- Prognosis
- Intervention
- Outcomes
Definition and Description of Examination
Process of collecting information and data on patient’s problems and why they are seeking PT.
Definition and Description of Evaluation
Interpreting collected data and information as a whole to determine overall function, diagnosis, prognosis, POC, goals, duration of PT, and discontinuation plans.
Definition and Description of Diagnosis
Label which describes dysfunction requiring PT interventions
Definition and Description of Prognosis
Predicted level of improvement, treatment goals, expected outcomes, duration and frequency, and interventions to be used.
Definition and Description of Intervention
Interaction of the PT or PTA to produce changes in condition by optimizing individual function.
Definition and Description of Outcomes
tests and observations used to determine the patient’s response to interventions and progress toward goals.
Role of PT and PTA within the Patient/Client Management Model
PT- Examination, Evaluation, Diagnosis, Prognosis
PTA and PT- Interventions and Outcomes
PTA roles related to patient care, documentation, and communication
The PTA’s role in the physical therapy process falls within interventions and outcomes of the Patient/Client Management Model. A PTA can provide all 9 categories of interventions, use clinical reasoning to determine the readiness of patients for interventions, consult with PT, perform tests and document measures, and modify care within POC.
9 Categories of Intervention
- Patient instruction
- Airway clearance techniques
- AD
- Biophysical agents
- Functional training (activities and participation)
- Integumentary repair and protection techniques
- Manual therapy
- Motor function training
- Thera Ex.
Essential components of POC
diagnosis
goals
interventions planned
proposed frequency and duration
discharge plans
Major reasons to document
To track progress
legal reasons
research evidence
insurance billing
Types of patient data found in medical record
demographics
diagnoses
problem lists
medications
vital signs
laboratory data
How can clinical decision-making be shown in the medical record?
A clinician can integrate the clinical decision-making process by documenting changes in patient status to concurrent changes in plan or care or plan to discuss changes in status with PT to revise POC.
Role of PTA in the clinical decision-making process
A PTA can assist in showing clinical decision-making by modifying interventions with POC and taking objective measures and comparing to the initial examination.
Reasonable and necessary criteria
- Must be a specific and effective treatment for the patient’s condition.
- Level of complexity to be provided by PT or PTA.
- The condition of the patient demonstrates the need for professional assistance.
- The amount, frequency, and duration of the services must be reasonable.
What is the difference between skilled care and maintenance care?
Skilled care is to complete a goal of improvement, but maintenance therapy is to help a patient stay at a current functional level and limit disease progression.
How can you document pt. response to treatment?
PT or PTA should document any patient complaints or reported functional improvements under the subjective section of the documentation.
Ethical obligations that pertain to documentation according to APTA
PTA shall ensure documentation accurately reflects the nature and extent of the service provided
PTA’s role in determining medical necessity
The PTA should report to PT if goals are met, are not being met promptly, and if interventions can be done without professional help to help determine medical necessity.
How does prognosis influence the need for medically necessary skilled care?
If the patient’s prognosis, is they will not improve and function is the new normal then applying physical therapy in a skilled setting will not benefit the patient due to skilled therapy being tailored to improvement.
