Quiz 2 Flashcards
What are the components of the patient/client management model that should be documented?
Examination, evaluation, diagnosis, prognosis, and interventions
- Pt’s condition or pathology
- impairments
- anticipated goals and expected outcomes
- interventions provided including education, communication with other disciplines and specific procedures
- the final outcome or result of the interventions
What can PT document vs PTA?
PT: examination, evaluation, diagnosis, prognosis and interventions, discharge
PTA: interventions only
What is the purpose of APTA Guidelines for Physical Therapy Documentation?
“provide (documentation) guidance for the physical therapy profession across all practice settings”
-serve as a foundation for developing documentation procedures
What are the basic principles for documentation?
- Be timely
- Entries must be thorough
- Entries must be clear and concise
- Be consistent
- Use objective language
- Write legibly
- Use blue or black ink
- Use scientific, medical terminology
- Entries must communicate skilled care
- Use abbreviations appropriately
- Write in third person
- Avoid skipping lines
- Use headings
- Use tables when indicated
- Document late entries
- Correct errors
- Date and authenticate all patient records
- Document missed appointments
- Document telephone, face-to-face, or electronic conversations related to patient care
- Document unusual or unexpected situations or results
- Indicated “continued” when using more than one page
What are the principles for documenting patient care?
Document the following types of information:
- Subjective information that helps demonstrate the patient’s status
- Changing in objective and measurable findings as they relate to the initial evaluation and the existing goals
- The pt’s reaction to treatment (+ or -)
- Progression/regression of the treatment plan including patient education
- communication or collaboration with other health care providers, the pt, and the pt’s family or caregivers
What are common reasons for denial of payment associated with inappropriate documentation methods?
- poor legibility
- incomplete documentation
- no documentation for date of service
- Abbreviations- too many, cannot understand
- Documentation does not support the billing (coding)
- Does not demonstrate skilled care
- Does not support medical necessity
- Does not demonstrate progress
- Repetitious daily notes showing no change in patient status
- Interventions with no clarification of time, frequency, duration
What are the sources of subjective data?
- patient
- pt family or caregivers
- pt medical chart
What types of date should be recorded in the subjective portion?
- Patient’s status
- Informed consent
- Pt’s response to interventions provided
- new problems or new complaints
- pertinent information not previously documented
How does subjective information inform the clinical decision making process?
-helps discern the pt’s affective response to the issues, allows PTA or PT to respond appropriately and modify intervention strategies
Why link subjective information in the interim note to the evaluative note?
Because it shows changes in the pt’s progress. Also it allows information to be compared to the initial eval.
What types of data should be recorded in the objective section?
- physical therapy intervention provided
- information that demonstrates the pt’s readiness to participate with PT
- information that demonstrate the pt’s response to the physical therapy provieded
Why is objective data important?
- useful for validating the need for PT
- demonstrate pt’s progress
- form a detailed picture of pt problems and are used to guide clinical decision making process
