Unit 2 Lecture Flashcards
describe the functions of documentation
- records quality of care & allows treatment to be replicated
- is a legal report of the treatment that protects the patient, facility, and therapist
- evidence of patient care - “if it isn’t written down, it didn’t happen”
- provides the basis of reimbursement for skilled patient care
- accountability of patient care
the standards of criteria for documentation are set by
- federal and state government
- professional associations
- accrediting agencies
- example: Joint Commission of Accreditation of Health (JCAHO)
- health care facilities
describe impairment, functional limitation, and disability
- IMPAIRMENT: a loss or abnormality of a physiological, psychological, or anatomical structure or function
- FUNCTIONAL LIMITATION: a restriction of the ability to perform an activity or a task in an efficient, typically expected, or competent manner
- DISABILITY: an inability to perform or a limitation in the performance of actions, tasks, and activities usually expected in specific social roles and physical environments
name the 6 categories of content for documentation
1 problem(s) requiring treatment
2 data relevant to pt’s medical or PT diagnosis
3 treatment plan; action(s) to address problem(s)
4 goals/outcomes of treatment plan
5 record of administration of treatment plan
6 effectiveness of treatment results
describe and know the differences between a medical diagnosis & a physical therapy diagnosis
MEDICAL DIAGNOSIS
- systemic disease or disorder
- determined by physician’s evaluation & diagnostic tests
PHYSICAL THERAPY DIAGNOSIS
- identification of movement system impairments
- related to impairments, functional limitations, and disabilities
describe and know the differences between a medical diagnosis & a physical therapy diagnosis
MEDICAL DIAGNOSIS
- systemic disease or disorder
- determined by physician’s evaluation & diagnostic tests
PHYSICAL THERAPY DIAGNOSIS
- identification of movement system impairments
- related to impairments, functional limitations, and disabilities
example:
- MED: Fx of R femur
- PT: loss of strength & ROM to R hip & knee due to fx
name the components of a SOAP note
Subjective data
Objective data
Assessment
Plan
describe subjective data
may reflect pt’s response to treatment, must be relevant
- information about pt’s history
- symptoms or complaints that caused pt to seek medical attention
- factors that reproduce symptoms
- pt’s lifestyle & functional needs prior to & following the disease/disorder
- pt’s goals or expectations regarding medical care
describe objective data
- reproducible & readily demonstrable
- data collected by measurements, tests, & observations
- written with 2 audiences in mind: PT/PTA who will be working with pt & reader untrained in PT (ex: insurance)
- helps determine effectiveness of interventions related to PT dx & pt’s progress towards POC goals
- illustrates intervention(s) required, the skills of trained physical therapy, and professional/medical necessity
what are general topics included in the “O” portion?
- results of measurements/tests
- description of pt’s function
- description of intervention provided
- PTA’s objective observations of pt
- a record of number of treatment sessions provided
- pt education included in treatment session
what should be included when describing pt function in the “O” portion?
- function skill (gait training, transfers, balance, etc)
- quality of movement
- level of assistance required
- purpose of assistance
- equipment used
- pt position (supine, sitting, etc)
- distance, time, wt
- type of surface
- environmental conditions
- cognitive status
- any complicating factors
what types of details should be included when discussing interventions used in the “O” portion?
- modality, activity, exercise
- reps, sets, distances
- equipment
- treatment parameters
- target treatment area
- treatment purpose
- patient positioning
- duration, frequency, rest breaks
- anything unique to particular treatment
SOAP notes must be
- legible
- written in INK
- no blank space
- signed
- dated
define: WB, NWB, PWB, TTWB, & WBAT
- WB: weight bearing
- NWB: non-weight bearing
- PWB: partial weight bearing
- TTWB: toe-touch weight bearing
- WBAT: weight bearing as tolerated
define t/f & s/p
- t/f: transfer
- s/p: status post
