Introduction to Documentation Flashcards
1
Q
Reasons for documenting
A
- record of patient/client management
- demonstrate clinical problem solving
- reimbursement
- provide proof of medical necessity
- provide proof of and need for skilled care
- communication
- outcomes research
- legal action
2
Q
General documentation guidelines
A
- documentation is required for every visit
- all handwritten entries should be made in ink with a signature
- charting errors should be corrected by drawing a single line through the error & initialing & dating the chart
- all documentation must include adequate identification of the patient/client & the physical therapist or PTA
- should include the referral mechanism & indication of no shows and cancellations
3
Q
History should include:
A
- general demographics
- social history
- employment
- growth and development
- living environment
- general health status
- social/health habits
- family history
- medical/surgical history
- current conditions
- functional status and activity level
- medications
- other clinical tests
4
Q
Cardiovascular/pulmonary system review should include:
A
- blood pressure
- edema
- heart rate
- respiratory rate
- oximetry
5
Q
Integumentary system review should include:
A
- pliability (texture)
- presence of scar formation
- skin color
- skin integrity
6
Q
Musculoskeletal system review should include:
A
- gross range of motion
- gross strength
- gross symmetry
- height
- weight
7
Q
Neuromuscular system review should include:
A
- gross coordinated movement
- motor function
8
Q
Communication ability, affect, cognition, language, and learning style should include:
A
- ability to make needs known
- consciousness
- expected emotional/behavioral responses
- learning preferences
- orientation
9
Q
Describe the evaluation
A
- leads to documentation of impairments, activity limitations, & participation restrictions
- general format: a problem list and a statement of assessment of key factors influencing the patient/client status
10
Q
Plan of care should include:
A
- overall goals stated in measurable terms that indicate the predicted level of improvement in functioning
- a general statement of interventions to be used
- proposed duration & frequency of service required to reach the goals
- anticipated discharge plans
11
Q
Describe goal writing
A
- Audience (who us doing the behavior)
- Behavior (the action being performed)
- Condition (description of conditions the behavior is to be performed)
- Degree (measurable term)
- Expected duration (amount of time expected for outcome)
12
Q
Daily note should include:
A
- Subjective (everything the patient tells you)
- Objective (everything you as the physical therapist did that day)
- Assessment (changes in patient impairment, activity limitation, and participation restriction status)
- Plan (documentation of plan for ongoing provision of services for the next visit)
