Documentation: Evaluation/Diagnosis and Assessment (wk 1)

Question 1

Why is documentation important? (8)

Answer 1

1. To serve as a record of patient care.
2. To convey our unique body of knowledge and our practice.
3. To communicate among different providers.
4. To be used for policy or research purposes.
5. To reflect appropriate provision of care in accordance with local, state, and federal regulations.
6. To record the episode of care of the patient/client.
7. To document care and instructions provided to the patient and their response to treatment.
8. To document any communication with individuals involved in the care of the patient/client.

Question 2

What are reasons for denial from insurance companies?

Answer 2

1. No documentation for date of service
2. Incomplete documentation
3. Documentation not understood due to abbreviations
4. Goals are not written as functional outcomes
5. Medical necessity is not identified clearly
6. Does not support the billing (coding)
7. Does not demonstrate progress
8. Does not demonstrate skilled care

Question 3

T/F The differential diagnosis list developed by the physical therapist may include several conditions

Answer 3

True

Question 4

T/F The physical therapist’s diagnosis is guided by patient/client responses to interventions

Answer 4

True

Question 5

What is a medical diagnosis?

Answer 5

label of pathology or disease

ex: Lumbar herniated disc

Question 6

What is a physical therapy diagnosis?

Answer 6

1. Where patient is feeling symptoms but also what can help them
2. Paralysis, increased tone with PROM difficulties
   ex: Right-sided lower extremity radiculopathy centralizing with repeated extension

Question 7

What is a primary diagnosis?

Answer 7

condition established to be chiefly responsible for patient to seek medical care
ex: Total knee replacement

Question 8

What is a secondary diagnosis?

Answer 8

any additional conditions that affect patient care
ex: Patient being treated s/p TKA with hypertension (can monitor properly to stay safe, but not being treated for hypertension)

Question 9

Based on the information gathered from the history and tests and measures, the physical therapist must first determine what three things?

Answer 9

1. Intervention appropriate
2. Consultation with another healthcare provider necessary
3. Intervention not indicated and referral is necessary

Question 10

What section of documentation with you interpret data from subjective and objective sections using sound clinical judgment?

Answer 10

Assessment

Question 11

T/F The assessment introduces new subjective or objective data.

Answer 11

False, is does NOT

Question 12

In the assessment, you generally summarize and link the impairments to what two things?

Answer 12

1. how it’s limiting them functionally

2. how they add up to pt/medical diagnosis they are coming in with

Question 13

The assessment will use what model to link medical and physical therapy dx with impairments, activity limitations, & participation restrictions?

Answer 13

ICF model

Question 14

Describe how to tie limited knee extension AROM -> limit gait -> limit ability to walk at work together:

Answer 14

Pt demonstrates lack of knee extension ROM Actively that is limiting ability to achieve terminal knee extension during stance phase of gait which is limiting ability to walk at work and reducing function overall at work.

Question 15

T/F Majority of users of the note will go to the assessment first to find out why patient requires physical therapy services.

Answer 15

True

Question 16

What are included in the impairments of the icf model?

Answer 16

Problems an individual may have in body function or structure

Question 17

What are included in the activity limitations of the icf model?

Answer 17

difficulty in executing tasks

a. ADLs (basic)
b. Functional mobility
c. Learning

Question 18

What are included in the Participation restrictions of the icf model?

Answer 18

problems in life roles

a. Work activities
b. Community activities
c. Leisure activities (focus less on this)
d. Relational activities

Question 19

What are included in the personal factors of the icf model?

Answer 19

a. Age/gender
b. Coping styles
c. Education/Profession
d. Past experiences

Question 20

What are included in the environmental factors of the icf model?

Answer 20

a. Social attitudes
b. Stress
c. Physical space
d. Legal/Social Structures’

Question 21

T/F Assessment does not need to outline the need for physical therapy services

Answer 21

False

Question 22

T/F Reporting patient has experienced a “decline in function” or “patient improving” in the assessment is not enough

Answer 22

true

Question 23

T/F The assessment Includes recommendations and actions taken to address concerns.

Answer 23

True

Question 24

T/F You do not need to include professional judgment for predicted functional outcome and the required duration of services to obtain this functional outcome in the assessment

Answer 24

False

Question 25

T/F The assessment can change based on new or changing information

Answer 25

True

Question 26

Therapy services are considered reasonable and necessary when the following conditions are met:

Answer 26

1. The services provided are consistent with the nature and severity of the illness, injury, and medical needs. (In line with pt/medical diagnosis)
2. The services provided are specific, safe, and effective treatment for the condition according to accepted medical practice.
3. There should be a reasonable expectation that observable improvement in functional ability will occur.
4. The services do not just promote the general welfare of the beneficiary (require skilled pt)

Question 27

If the patient shows other symptoms for something there aren’t coming for you for, can you immediately treat that?

Answer 27

No, must do a new/separate assessment

Question 28

Document complications and safety issues as a result of the patient current status. As examples:

Answer 28

1. Fall Risk
2. Reduced mobility - increase risk for further complications
3. Inability to complete tasks (ie, activities of daily living)

Question 29

T/F A therapist’s skill may also be required for safety reason.

Answer 29

True, if patient is fall risk, should be working on sit to stands in clinic, not at home

Question 30

Ex: Patient educated in the use of progressive exercises to facilitate trunk stabilization for improved balance during gait
Why important that we mention this?

Answer 30

individual interventions found in objective section, but this is why we do intervention for what impairment and this is how it will improve their function

Question 31

Ex: Training provided in donning/doffing lower extremity prosthesis with verbal and manual cues for technique and safety
Why important that we mention this?

Answer 31

education on tech and safety

Question 32

Ex: Ambulation training with standard walker. Patient requires frequent monitoring of vital signs due to cardiac risk factors
Why important that we mention this?

Answer 32

skill is monitoring

Question 33

Ex: Patient demonstrates consistently good balance on level surface, therefore progressed patient to performing standing balance activities on unstable surface to decrease fall risk and increase community ambulation safety
Why important that we mention this?

Answer 33

why progress intervention and why my skills were needed to make the progression

Question 34

How do you document progression?

Answer 34

Document previous as compared to current function – how are they progressing and what they need to continue to get better at

Question 35

What are some standar outcome measures used in demonstration of progression?

Answer 35

1. percentages, levels of assistance or function
2. ROM
3. MMT
4. Balance assessment