Documentation Guidelines for MSK PT Flashcards

1
Q

What is the purpose of documentation

A
  • Gather pt info (S and O)
  • interventions
  • describe your assessments
  • establish prognosis
  • document your time
  • track pts progression/regression

“if its not written down, it did not happen”

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2
Q

Who sees your documentaion

A
  • other PTs
  • MDs
  • Medicare
  • Insurance
  • Attorneys
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3
Q

What are the different types

A
  • initial eval
  • daily notes
  • progress notes
  • D/C notes
  • Notes to 3rd party payers
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4
Q

What makes initial evaluation (subjective)

A
  • history
  • pain
  • aggravating/relieving
  • PMH
  • imaging/meds
  • pt-rated outcome score
  • pts goals
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5
Q

what makes up initial eval (objective

A
  • impairments

- dx, guide treatment, important to assess treatment outcome

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6
Q

What makes up initial eval (assessment)

A

PT dx and need for PT

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7
Q

what makes up initial eval (plan)

A
  • goals

- fx

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8
Q

What is the format of a daily note

A

SOAP note format

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9
Q

What are the components of daily note (subjective)

A
  • pain
  • Changes since last visit
  • response to last visit
  • HEP: completion rate, ability to reproduce with % of verbal cues
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10
Q

what are the components of daily note (objective)

A
  • interventions (ex, manips, modalities, tapin/bracing)
  • any impairments reassessed
  • pt education
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11
Q

What are the components of a daily note (assessment)

A
  • pts response to treatments

- why the pt needs skilled intervention

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12
Q

What makes up a daily note (Plan)

A
  • continue PT
  • interventions to add next visit
  • fx
  • RTMD
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13
Q

what makes up a progress note (subjective)

A
  • pain
  • overall; are you better or worse since start of PT
  • primary cc
  • changes since last visit? since starting PT?
  • response to last visit
  • aks or repeat pt rated outcomes
  • HEP: completion rate, ability to reproduce with % of verbal cues required
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14
Q

What information would you put in the objective portion of a progress not

A
  • reassessments but only for relevant measures to determine progression/regression of treatment
  • documentation of any specific parameters for treatment
  • Dc of any rx procedures that you were performing prior to this rx, with appropriate rationale
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15
Q

What makes up progress note (assessment)

A
  • your assessment of pts progression/regression
  • general health
  • mental health
  • function/disability: any change
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16
Q

what makes up progress note (plan)

A
  • continue PT per protocol
  • continue PT (fx)
  • recommend imaginig
  • recommend Hold PT
  • recommend DC PT
17
Q

What is a discharge note

A

Similar to progress note but reassess impairments, goals, and outcome surveys; along with pt education

18
Q

what are the general guidelines for documentation

A
  • document rationale for rx: reimbursement and healthcare professionals
  • documentation for reimbursement
  • is there a standard for documentation of exercises
  • what do 3rd party payers look at (pain, impairments, function, outcome surveys