Week 12 - Documentation Flashcards
1
Q
Why do we document? Why is it important?
A
- Communication
- Legal record
- Discharge planning
- Demonstrate compliance
- Demonstrate skilled services
2
Q
What are the 4 types of notes taken?
A
- Initial Note
- Daily Note
- Progress Note/Reeval
- Discharge Note
3
Q
The initial note is done on the ________ and includes the _________ and _____.
A
- first visit
- initial eval and POC
4
Q
The progress note is done every ___ visits or every __ or __ days OR when the patient _______ changes unexpectedly or does not progress as expected.
A
- 10
- 30 or 60 days
- condition
5
Q
Documenting tests and measures:
A
- Record of results of therapist observation, tests, and measures
- Use the objective info to formulate goals and demonstration of progress
- Highly dependent and variable on the patient population and diagnosis
- Organized into categories to improve readability
- Brevity and clarity (table may be most appropriate way to present info)
6
Q
Documenting goniometry:
A
- Indicate type or ROM assessed (AROM,PROM)
- Record joint, which motion, and measurement taken
- Try not to use negative numbers
7
Q
_____________ can help inform the rest of your documentation.
A
outcome measures
8
Q
What are the two primary categories of outcome measures?
A
- Self-reported (Patient satisfaction, pain, QOL)
- Performance based
9
Q
Goal writing should be ____ and used to _________
A
- clear
- determine
10
Q
Goal writing should be used to determine what 3 things?
A
- progress
- prognosis; duration and frequency of the episode of care
- conclusion of care and intervention plan
11
Q
Goal writing needs to be what?
A
- patient centered
- unbiased and objective
- quantifiable
- relates to a particular use (functional)
- have a time frame
