PT 201- documentation Flashcards
what does the acronym SOAP stand for?
Subjective Objective Assessment Plan (E=education)
what makes up the “S”?
- S makes up part of the examination
definition: This section includes history information gained from interviewing/questioning the patient or caregiver, other individuals, consultation with other members of team, and medical record review - past/current problems based on review of medical record (results of medications)
- family history of disease
- an example would be, “ a patient reports lower back pain after sitting”
what makes up the “O”?
- O makes up the other part of examination
definition: this section includes information that was gathered by the physical therapist completing the appropriate systems review assessments and tests and measures. - results of physical therapy examination like test scores, measures, and functional skills
- it is anything that is numerical data
What makes up the “A”?
- A makes up the evaluation/diagnosis/prognosis
definition: this section summarizes the findings from subjective and objective sections and includes the formulation of short term and long term outcomes/goals - list of patients needs
- short term and long term goals
- ABCD
what is the difference between a short term and a long term goal?
- long term is written first with short term based on long term
- short term are written as steps along the way to achieving long term
- short term are revised periodically as per time period indicated or if patient has achieved the behavior as stated
- short term direct immediate course of intervention
what does the acronym ABCD stand for?
A= audience (who will exhibit the skill) B= behavior (what will the person do) C= Condition (under which circumstances the skill will be done, For example, position, equipment, physical assistance, etc. that must be available for the patient to before the behavior) D= degree (how well the behavior will be done. For example, # feet, # reps, time, etc)
List the ABCD for this following scenario:
Mr. Hope will wrap his residual limb with 3” elastic wrap with v.c’s within 1 week to prepare for prosthetic delivery and gait training
A: Mr. Hope
B: Will wrap his residual limb
C: with 3” elastic wrap with v.c
D: within 1 week
**sometimes F which would be to prepare for prosthetic delivery
List the ABCD for this following scenario:
Jane will propel her wheelchair 100’ on the tile floor within 3 minutes independently 2/3 trials
A: Jane
B: will propel her wheelchair
C: independently on tile floor
D: in 3 minutes ever 2/3 trials for 100’
List the ABCD for this following scenario:
Jason will ascend 5 stairs with quad cane and WBAT on L LE with minimal assist 1/3 trials on 2 consecutive days within 1 week
A: Jason
B: will ascend 5 stairs
C: with quad cane and WBAT on L LE with minimal assistance
D: 2 consecutive days within a week 1/3 trials
What makes up the “P”?
- P makes up the Intervention
definition: this section is the final step in documentation and includes frequency per day or per week that will be seen, intervention the patient will receive (specificity here will depend on facility), and if discharge note, where the patient is going and the number of times the patient was seen in therapy. It also frequently includes location of treatment, intervention progression, plans for further assessment/reassessment, plans for discharge, equipment needs, referral to other services.
what is the purpose of documentation?
- if not documented it didn’t happen
- track progress
- communication between practices
- to get paid
- research
- look at patients medical records to determine if PT should take places
What are the 6 parts of the Disablement-Enablement Model?
Examination Evaluation Diagnosis Prognosis Intervention Outcomes
Look over ICF
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