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DPT 522 > Quiz 2 > Flashcards

Quiz 2 Flashcards

1
Q

what is the purpose of the medical record?

A

complete and accurate recording of care

basis for planning and treatment

means of communication for attending healthcare professionals

description of patient services

verification of services for payers

data for health research

secondarily: education of staff, providers, and students; compliance and accreditation; research, policy making, industry,

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2
Q

authentication of the medical record

A

date and signature of the attending PT

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3
Q

utilization

A

an audit of care done on a practice to see if something is being over utilized compared to surrounding areas

fraud and abuse

medical malpractice

sometimes documentation wording will raise red flags for insurance companies

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4
Q

reason for denial

A

if you get a denial, it is generally due to documentation error

billing doesn’t allow more than 5 ICD codes, so yours may be dropped bc nursing, OT, PT all put in their diagnoses=creates a reason for denial.

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5
Q

general principles of documentation

A

need to be legible

errors are crossed out once and dated and initialed

timely documentation done immediately or after treatment

spelling and grammar are essential

abbreviations should come from standardized list

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6
Q

WNL

A

w/in normal limits

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7
Q

PMH

A

past medical history

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8
Q

BID

A

twice a day

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9
Q

MMT

A

manual muscle tests

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10
Q

OA

A

osteoarthritis

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11
Q

ROM

A

range of motion

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12
Q

PROM

A

passive range of motion

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13
Q

AROM

A

active range of motion

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14
Q

WB

A

weight bearing

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15
Q

WHO

A

world health organization

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16
Q

HEP

A

home exercise program

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17
Q

LE

A

lower extremity

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18
Q

what is the disability model?

A

the framework for the Guide to PT Practice

categorizes the impact of medical conditions on function

4 categories

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19
Q

what are the 4 categories of the disablement model?

A

pathology, impairment, functional limitation, and disability

20
Q

what is the ICF model and what does it involve?

A

standardized way of describing conditions

determine the health condition, what body functions/ structures/activities/ participation are affected, what the personal/environmental factors are, an d what the plan of care is

21
Q

what are the components of the patient/client model?

A

examination, evaluation, diagnosis, prognosis, and intervention

22
Q

what is the examination?

A

collection of data

screening and performing tests and measures

23
Q

what is the evaluation?

A

synthesizing data from the examination leads to diagnosis, prognosis, and plan for intervention

clinical decision making

24
Q

what is the diagnosis?

A

relates to the impairment to function and the patient problem list

25
Q

what is the prognosis?

A

potential for improvement

poor, fair, good, or excellent

need to be at least fair to get to rehab hospital

26
Q

what is the intervention?

A

what the PT decides to do based on their eval, exam, diagnosis, and prognosis

27
Q

what is a progress note?

A

notes subjective and objective changes in the patient’s status

recorded weekly (about every 7-10 days)

home health may be done every 30 days or after the 14th visit

28
Q

what is a reassessment note?

A

gathering subjective and objective data based on what was collected on the initial visit

document any progress being made

recorded monthly (every 30 days)

some insurances may require it every 2 weeks instead of monthly

29
Q

what is a discharge note?

A

patient’s final subjective and objective status

compares the initial and discharge data

shows the patient has met their goals

needed if a patient stops showing up to PT

30
Q

SOAP note

A

subjective: what the patient, family member, or significant other says the patient feels or is doing, only as relevant to this episode of care

objective: what the PT performs/observes/inspects in a reproducible manner relative to the episode of care

assessment: analysis for the s/s; creates a picture of where the patient is today; DON’T RELIST THE OBJECTIVE DATA

plan: treatment developed to meet the goals or objectives

31
Q

subjective info

A

chief complaint-main reason for seeking medical attention

history of present illnesses (onset, location, frequency, duration, severity, and quality of symptoms)

past medical history

review of systems (systematic injury into patient’s general health and organ systems)

OLD CARTS

32
Q

OLD CARTS

A

Onset
Location
Duration

Character
Alleviating/Aggravating factors
Radiation
Temporal pattern (time of day)
Severity

33
Q

objective info

A

balance and baseline tests

no interpretation, just test result-can be bulleted

reflects what the PT performs, observes, or inspects in a reproducible manner

vitals, assessments, tests and measures, treatments, equipment, procedures, direction/patient education

34
Q

what is the assessment?

A

assesses the patient’s progress through a systematic analysis of the problem, possible interaction, and status changes

DO NOT REPEAT OBJECTIVE DATA

identify problems based on subjective and objective info (listed in order of importance)

provide reasoning and evidence

35
Q

SMART goals

A

specific, measure able, attainable, realistic, and time-bound

36
Q

functional outcomes

A

associated with patient’s daily activities (ability to return to sports for example)

37
Q

what are the 2 types of goals?

A

body structure/function

activity

38
Q

what is a body structure/function goal?

A

patient will improve [power, strength, sensory integration] as evidenced by an increase in [test & measurement] to allow for [ activity/participation , e.g. PSFS, outcome measure] in time frame​

39
Q

what is an activity goal?

A

patient will improve [an limitation in activity e.g. maintaining static balance, walking level surfaces] as evidenced by an increase in [test & measurement, e.g. gait velocity] to allow for [participation, e.g. PSFS, measures] in time frame​

40
Q

how long are short-term goals?

A

0-14 days

0-3 months

41
Q

how long are long-term goals?

A

30-60 days

3-6 months

42
Q

what is included in defensible documentation?

A

identification of the person

description of the movement/activity

a connection of the movement/activity to a specific function

specific conditions in which the activity will be performed

factors for measuring the outcome

time frame for achieving the goal

43
Q

what factors influence outcome?

A

co-morbidities, conmittent diagnosis, complexities, and complicating factors

44
Q

what are some possible reasons for a claim denial?

A

inadequate information

billing did not match documentation

goals did not match the problems or diagnosis

patient did not require the skills of a physical therapist

potential for improvement is not identified

need for skilled therapy is not identified

it is really maintenance therapy provided

45
Q

when is a treatment medically necessary?

A

when the treatment is of such sophistication or complexity and/or the patient is a complexity of that, and if the treatment can only be safely and effectively performed by a licensed PT or PTA under the direct supervision of a therapist in a private practice setting

46
Q

medical necessity

A

patient need

the PT demonstrates that the treatment is supported by evidenced based practice, clinical reasoning and judgment and that without treatment there is little expectancy for the patient to improve

DPT 522 (1 decks)

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