Guidelines: Physical Therapy Documentation of Patient/Client Management Flashcards
Guidelines: PT Documentation of Patient/Client Management
Physical therapy examination, evaluation, diagnosis, prognosis, and plan of care (including interventions) shall be:
- ?
- ?
- ?
by the physical therapist who performs the service.
Physical therapy examination, evaluation, diagnosis, prognosis, and plan of care (including interventions) shall be documented, dated, and authenticated by the physical therapist who performs the service.
- Interventions provided by the physical therapist or selected interventions provided by the physical therapist assistant under the direction and supervision of the physical therapist are documented, dated, and authenticated by the physical therapist or, when permissible by law, the physical therapist assistant.
Guidelines: PT Documentation of Patient/Client Management
The process used to verify that an entry is complete, accurate and final = ?
Authentication: The process used to verify that an entry is complete, accurate and final.
Guidelines: PT Documentation of Patient/Client Management
The main documentation elements of patient/client management:
1. ?
2. ?
3. ?
4. ?
The main documentation elements of patient/client management:
1. initial examination/evaluation
2. visit/encounter
3. reexamination
4. discharge or discontinuation summary.
Guidelines: PT Documentation of Patient/Client Management
Includes data obtained from the history, systems review, and tests and measures = ?
Examination: Includes data obtained from the history, systems review, and tests and measures.
Guidelines: PT Documentation of Patient/Client Management
- A thought process that may not include formal documentation.
- It may include documentation of the assessment of the data collected in the examination and identification of problems pertinent to patient/client management = ?
Evaluation: Evaluation is a thought process that may not include formal documentation. It may include documentation of the assessment of the data collected in the examination and identification of problems pertinent to patient/client management.
Guidelines: PT Documentation of Patient/Client Management
Indicates level of impairment, activity limitation and participation restriction determined by the physical therapist. May be indicated by selecting one or more preferred practice patterns from the Guide to Physical Therapist Practice = ?
Diagnosis: Indicates level of impairment, activity limitation and participation restriction determined by the physical therapist. May be indicated by selecting one or more preferred practice patterns from the Guide to Physical Therapist Practice.
Guidelines: PT Documentation of Patient/Client Management
Provides documentation of the predicted level of improvement that might be attained through intervention and the amount of time required to reach that level = ?
Prognosis: Provides documentation of the predicted level of improvement that might be attained through intervention and the amount of time required to reach that level. Prognosis is typically not a separate documentation elements, but the components are included as part of the plan of care.
Guidelines: PT Documentation of Patient/Client Management
Typically stated in general terms, includes goals, interventions planned, proposed frequency and duration, and discharge plans = ?
Plan of care: Typically stated in general terms, includes goals, interventions planned, proposed frequency and duration, and discharge plans.
Guidelines: PT Documentation of Patient/Client Management
Documentation of a ** or ** , often called a progress note or daily note, documents sequential implementation of the plan of care established by the physical therapist, including changes in patient/client status and variations and progressions of specific interventions used. Also may include specific plans for the next visit or visits = ?
Visit/Encounter:
Documentation of a visit or encounter, often called a progress note or daily note, documents sequential implementation of the plan of care established by the physical therapist, including changes in patient/client status and variations and progressions of specific interventions used. Also may include specific plans for the next visit or visits.
Guidelines: PT Documentation of Patient/Client Management
Documentation of _ includes data from repeated or new examination elements and is provided to evaluate progress and to modify or redirect intervention = ?
Reexamination:
Documentation of reexamination includes data from repeated or new examination elements and is provided to evaluate progress and to modify or redirect intervention.
Guidelines: PT Documentation of Patient/Client Management
Documentation is required following conclusion of the current episode in the physical therapy intervention sequence, to summarize progression toward goals and discharge plans = ?
Discharge or Discontinuation Summary:
Documentation is required following conclusion of the current episode in the physical therapy intervention sequence, to summarize progression toward goals and discharge plans.
Guidelines: PT Documentation of Patient/Client Management
Documentation of ? may include the following:
- General demographics
- Social history
- Employment/work (Job/School/Play)
- Growth and development
- Living environment
- General health status (self-report, family report, caregiver report) * Social/health habits (past and current)
- Family history
- Medical/surgical history
- Current condition(s)/Chief complaint(s)
- Functional status and activity level
- Medications
- Other clinical tests
History
Guidelines: PT Documentation of Patient/Client Management
Documentation of ? may include gathering data for the following systems:
Cardiovascular/pulmonary o Blood Pressure
* Edema
* Heart Rate
* Respiratory Rate
Integumentary
* Pliability (texture)
* Presence of scar formation o Skin color
* Skin integrity
Musculoskeletal
* Gross range of motion
* Gross strength
* Gross symmetry
* Height
* Weight
Neuromuscular
* Gross coordinated movement (eg, balance, locomotion, transfers,
* and transitions)
* Motor function (motor control, motor learning)
Systems Review
Guidelines: PT Documentation of Patient/Client Management
Documentation of ? may also address communication ability, affect, cognition, language, and learning style:
* Ability to make needs known
* Consciousness
* Expected emotional/behavioral responses
* Learning preferences (eg, education needs, learning barriers)
* Orientation (person, place, time)
Systems Review
Guidelines: PT Documentation of Patient/Client Management
Documentation of ? may include findings for the following categories:
* Aerobic Capacity/Endurance
* Anthropometric Characteristics
* Arousal, attention, and cognition
* Assistive and adaptive devices
* Circulation (Arterial, Venous, Lymphatic)
* Cranial and Peripheral Nerve Integrity
* Environmental, Home, and Work (Job/School/Play) Barriers
* Gait, locomotion, and balance
* Joint Integrity and Mobility
* Motor Function
* Muscle Performance
Tests and Measures
