Exam 1 Materials

Question 1

Documentation Categories

Answer 1

History
Systems Review
Tests & Measures
Evaluation
Diagnosis
Prognosis
Plan of Care
Re-examination
Visit/Encounter Notes
Discharge Summary

Question 2

Top 10 Tips for Defensible

Answer 2

1. Limit use of abbreviations
2. Date & sign all entries
3. Document legibly
4. Report progress towards goals regularly
5. Document at the time of the visit when possible
6. Clearly identify note types (e.g. progress notes, daily notes, etc)
7. Include all related communications
8. Include missing/cancelled visit
9. Demonstrate skilled care
10. Demonstrate discharge planning throughout the episode of care

Question 3

Top 10 Payer Complaints about Documentation (reasons for denial)

Answer 3

1. Poor legibility
2. Incomplete documentation
3. No documentation of date of service
4. Abbreviations – too many, cannot understand
5. Documentation does not support the billing (coding)
6. Does not demonstrate skilled care
7. Does not support medical necessity
8. Does not demonstrate progress
9. Repetitious daily notes showing no change in pt status
10. Interventions w/ no clarification of time, frequency, duration

Question 4

History Sections

Answer 4

Demographic information
Current Conditions/Chief Complaints
Pt Goals
Prior Level of Function
Social Hx
Employment Status
Living Environment
General Health Status
Social/Health Habits
Family Health Hx
Pt's Medical/Surgical History
Functional Status/Activity Level
Medications
Other Clinical Tests

Question 5

Systems Review Sections

Answer 5

Cardiovascular/Pulmonary System
Integumentary System
Musculoskeletal System
Neuromuscular System
Communication
Affect
Cognition
Learning Barriers
Learning Style
Education Needs

Question 6

Tests & Measures Option 1

Answer 6

• Ambulations
  
  • Transfers
  • Balance
  • ROM
  • Strength
  • Sensation

Question 7

Tests & Measures Option 2

Answer 7

• Ambulation
  
  • ADL’s
  • IADL’s
  • UE
  • LE
  • Trunk

Question 8

Tests & Measures Option 3

Answer 8

• Ambulation
  
  • ADL’s
  • IADL’s
  • R extremities
  • L extremities
  • Trunk

Question 9

Evaluation Contains

Answer 9

• Summary of deficits in function & impairments
  
  • Describe the impact that functional deficits in function & impairments
  • Justify further therapy
  • Discussion of pt progress in therapy
  • Inconsistencies between examination findings
  • Further testing needed (other examination not completed during initial therapy session)
  • Referral to another practitioner due to findings in screening

Question 10

Diagnosis Contains

Answer 10

Describe the impact that functional deficits or impairments have on the person’s ability to function in their environment (PRIMARY)

List other functional deficits/impairments that the pt could have (SECONDARY)

Question 11

Prognosis Contains

Answer 11

Looks at functional deficits/impairments, pt goals, living environment THEN predicts level of improvement & time needed to reach that level

Other things included: factors influencing prognosis, justifications of goals set, treatment plan, clarification of problem, future services that may be needed