Regulatory Issues and Documentation Overview

Question 1

Informed Consent

Answer 1

• code of ethics: Principle 2C: provide necessary information to allow patients to make informed decisions
• risks, benefits, costs, alternatives to treatment
• what is the treatment plan

Question 2

Malpractice

Answer 2

• improper performance of treatment procedure
• injuries from modalities
• inadequate supervision of patients and support personnel
• inappropriate selection of treatment techniques
• failure to perform appropriate tests/measures
• injuries from equipment failure
• improper, illegal or negligent happenings (no mention of intent)
• incident reports are in house, not for medical record

Question 3

Law vs. Regulation vs. Policy

Answer 3

• law: governmental statements of what we must do-KPTA
• regulation: state how intent of law should be carried out: carry force of law
• policy: written by non governmental agencies-APTA

Question 4

Risk Management: Prevention vs. Management

Answer 4

-prevention: use of gait belts for transfers, specific places to keep equipment, wiping down surfaces, changing pillowcases

Question 5

Confidentiality

Answer 5

• PT code of ethics: PTs must protect confidential patient/client information and may disclose confidential information only when allowed or as required by law
• HIPPA

Question 6

Patient/Client Management OVERVIEW

Answer 6

• 5 elements of P/C Management Model
• initial patient encounter
• interim notes
• ongoing assessments and re-evaluations
• discharge notes
• Examination, Evaluation, Diagnosis, Prognosis, Intervention, Outcome

Question 7

Examination

Answer 7

• history
• systems review/screening: musculoskeletal, neuromuscular, cardiovascular/pulmonary, integumentary
• tests and measures: rule in/out reasons for causes of impaired body structures and function, activity limitations, and participation restrictions
• number and depth of tests depend on patient

Question 8

Assessment and Plan

Answer 8

• summary: what is wrong with patient?
• clinical judgement
• integrate history with findings in tests and measures
• develop a problem list
• make PT diagnosis (movement/function)

Question 9

Prognosis

Answer 9

• potential for improvement
• contains specific goals: must be objective and measurable: should represent ultimate discharge plan, long term and short term goals

Question 10

Plan of Care (Intervention Plan)

Answer 10

• medical necessity justification
• plans for referral
• timing: amount-daily, frequency-weekly, duration-total length of episode of care

Question 11

Interim Documentation

Answer 11

• daily treatment notes: date, procedure/modality provided/billed, coded treatment minutes, total treatment time, signature and credentials
• interim assessment/re-evaluations: ongoing vs. formal. vs re-evaluation (look these up and fix later)