Quiz 2 Flashcards
what is the purpose of the medical record?
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,
authentication of the medical record
date and signature of the attending PT
utilization
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
reason for denial
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.
general principles of documentation
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
WNL
w/in normal limits
PMH
past medical history
BID
twice a day
MMT
manual muscle tests
OA
osteoarthritis
ROM
range of motion
PROM
passive range of motion
AROM
active range of motion
WB
weight bearing
WHO
world health organization
HEP
home exercise program
LE
lower extremity
what is the disability model?
the framework for the Guide to PT Practice
categorizes the impact of medical conditions on function
4 categories
what are the 4 categories of the disablement model?
pathology, impairment, functional limitation, and disability
what is the ICF model and what does it involve?
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
what are the components of the patient/client model?
examination, evaluation, diagnosis, prognosis, and intervention
what is the examination?
collection of data
screening and performing tests and measures
what is the evaluation?
synthesizing data from the examination leads to diagnosis, prognosis, and plan for intervention
clinical decision making
what is the diagnosis?
relates to the impairment to function and the patient problem list
what is the prognosis?
potential for improvement
poor, fair, good, or excellent
need to be at least fair to get to rehab hospital
what is the intervention?
what the PT decides to do based on their eval, exam, diagnosis, and prognosis
what is a progress note?
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
what is a reassessment note?
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
what is a discharge note?
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
SOAP note
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
subjective info
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
OLD CARTS
Onset
Location
Duration
Character
Alleviating/Aggravating factors
Radiation
Temporal pattern (time of day)
Severity
objective info
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
what is the assessment?
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
SMART goals
specific, measure able, attainable, realistic, and time-bound
functional outcomes
associated with patient’s daily activities (ability to return to sports for example)
what are the 2 types of goals?
body structure/function
activity
what is a body structure/function goal?
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
what is an activity goal?
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
how long are short-term goals?
0-14 days
0-3 months
how long are long-term goals?
30-60 days
3-6 months
what is included in defensible documentation?
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
what factors influence outcome?
co-morbidities, conmittent diagnosis, complexities, and complicating factors
what are some possible reasons for a claim denial?
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
when is a treatment medically necessary?
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
medical necessity
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
