Documentation: Evaluation/Diagnosis and Assessment (wk 1) Flashcards
Why is documentation important? (8)
- To serve as a record of patient care.
- To convey our unique body of knowledge and our practice.
- To communicate among different providers.
- To be used for policy or research purposes.
- To reflect appropriate provision of care in accordance with local, state, and federal regulations.
- To record the episode of care of the patient/client.
- To document care and instructions provided to the patient and their response to treatment.
- To document any communication with individuals involved in the care of the patient/client.
What are reasons for denial from insurance companies?
- No documentation for date of service
- Incomplete documentation
- Documentation not understood due to abbreviations
- Goals are not written as functional outcomes
- Medical necessity is not identified clearly
- Does not support the billing (coding)
- Does not demonstrate progress
- Does not demonstrate skilled care
T/F The differential diagnosis list developed by the physical therapist may include several conditions
True
T/F The physical therapist’s diagnosis is guided by patient/client responses to interventions
True
What is a medical diagnosis?
label of pathology or disease
ex: Lumbar herniated disc
What is a physical therapy diagnosis?
- Where patient is feeling symptoms but also what can help them
- Paralysis, increased tone with PROM difficulties
ex: Right-sided lower extremity radiculopathy centralizing with repeated extension
What is a primary diagnosis?
condition established to be chiefly responsible for patient to seek medical care
ex: Total knee replacement
What is a secondary diagnosis?
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)
Based on the information gathered from the history and tests and measures, the physical therapist must first determine what three things?
- Intervention appropriate
- Consultation with another healthcare provider necessary
- Intervention not indicated and referral is necessary
What section of documentation with you interpret data from subjective and objective sections using sound clinical judgment?
Assessment
T/F The assessment introduces new subjective or objective data.
False, is does NOT
In the assessment, you generally summarize and link the impairments to what two things?
- how it’s limiting them functionally
2. how they add up to pt/medical diagnosis they are coming in with
The assessment will use what model to link medical and physical therapy dx with impairments, activity limitations, & participation restrictions?
ICF model
Describe how to tie limited knee extension AROM -> limit gait -> limit ability to walk at work together:
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.
T/F Majority of users of the note will go to the assessment first to find out why patient requires physical therapy services.
True
What are included in the impairments of the icf model?
Problems an individual may have in body function or structure
What are included in the activity limitations of the icf model?
difficulty in executing tasks
a. ADLs (basic)
b. Functional mobility
c. Learning
What are included in the Participation restrictions of the icf model?
problems in life roles
a. Work activities
b. Community activities
c. Leisure activities (focus less on this)
d. Relational activities
What are included in the personal factors of the icf model?
a. Age/gender
b. Coping styles
c. Education/Profession
d. Past experiences
What are included in the environmental factors of the icf model?
a. Social attitudes
b. Stress
c. Physical space
d. Legal/Social Structures’
T/F Assessment does not need to outline the need for physical therapy services
False
T/F Reporting patient has experienced a “decline in function” or “patient improving” in the assessment is not enough
true
T/F The assessment Includes recommendations and actions taken to address concerns.
True
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
False
T/F The assessment can change based on new or changing information
True
Therapy services are considered reasonable and necessary when the following conditions are met:
- The services provided are consistent with the nature and severity of the illness, injury, and medical needs. (In line with pt/medical diagnosis)
- The services provided are specific, safe, and effective treatment for the condition according to accepted medical practice.
- There should be a reasonable expectation that observable improvement in functional ability will occur.
- The services do not just promote the general welfare of the beneficiary (require skilled pt)
If the patient shows other symptoms for something there aren’t coming for you for, can you immediately treat that?
No, must do a new/separate assessment
Document complications and safety issues as a result of the patient current status. As examples:
- Fall Risk
- Reduced mobility - increase risk for further complications
- Inability to complete tasks (ie, activities of daily living)
T/F A therapist’s skill may also be required for safety reason.
True, if patient is fall risk, should be working on sit to stands in clinic, not at home
Ex: Patient educated in the use of progressive exercises to facilitate trunk stabilization for improved balance during gait
Why important that we mention this?
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
Ex: Training provided in donning/doffing lower extremity prosthesis with verbal and manual cues for technique and safety
Why important that we mention this?
education on tech and safety
Ex: Ambulation training with standard walker. Patient requires frequent monitoring of vital signs due to cardiac risk factors
Why important that we mention this?
skill is monitoring
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?
why progress intervention and why my skills were needed to make the progression
How do you document progression?
Document previous as compared to current function – how are they progressing and what they need to continue to get better at
What are some standar outcome measures used in demonstration of progression?
- percentages, levels of assistance or function
- ROM
- MMT
- Balance assessment
