Week 5 Flashcards
What is a SOAPG note?
It is intended to formulate organized medical record and align with patient/client management process
What is an initial evaluation?
The documentation of the first visit with a patient
What is progress note?
The formal reassessment of a patient
What is a daily note?
The documentation of the PT session
What is a discharge note?
Documentation performed when a patient is discharges from care
What does the S in the SOAPG note stand for, what is its intent?
- S: subjective
- Intent: assist practitioner with examination planning, setting goals, planning and response to treatment and patient compliance
What is included in the S in SOAPG note?
- Chief complaint (aggravation and easing factors)
- Contents from the subjective exam
- Functional status/activity level
- Can include direct patient quotes
What does the O in the SOAPG note stand for, what is its intent?
- O: objective
- Intent: Where results of tests, measures, and observations are recorded. Information from reassessment during treatment progression
What is included in the O in SOAPG note?
- Appearance
- Range of motion measurements
- Manual muscle testing grades
- Special tests
- Vitals
- Gait and/or transfer abilities
- Functional/Performance measures
- Interventions performed (in a daily note)
What does the A in the SOAPG note stand for, what is its intent?
- A: assessment
- Intent: capture the evaluation of the examination and/or progress through therapy
What is included in the A in SOAPG note?
- Functional deficits and/or impairments
- Disability levels
- Functional status/activity level
- Justification for further therapy
- PT diagnosis and prognosis
What is a PT diagnosis?
AKA: ICF model. Provides a rationale for the need to categorize function beyond a diagnostic category. Compliments ICD-10 coding
What does the ICF model of disability do?
- Helps us look at the health condition(disorder or disease)
- Looks at body function and structure
- Looks at the activity level of the patient
- Looks at how the patient participates within the level of their environment
- Looks at contextual factors
What are contextual factors?
Personal or environmental factors that can sometimes play into the patient’s overall condition or prognosis.
What are body functions as it relates to the ICF?
Physiological functions of body systems (including psychological function)
What are body structures as it relates to the ICF?
Anatomical parts of the body such as organs, limbs and their components
What are impairments as it relates to the ICF?
Problems in body function or structure such as significant deviation or loss
What are activities as it relates to the ICF?
The execution of a task or action by an individual
What is participation as it relates to the ICF?
The involvement in a life situation
What are activity limitations as it relates to the ICF?
Difficulties an individual may have in executing activities
What are participation restrictions as it relates to the ICF?
Problems an individual may experience in involvement in life situations
What are environment factors as it relates to the ICF?
Make up the physical, social and attitudinal environment in which people live and conduct their lives
____ is determined following the PT diagnosis, are expectations for functional recovery/remedy for the patient’s problem.
Prognosis
A prognosis is influenced by ___ and contextual factors may play a major role on it
A prognosis is influenced by examination findings and contextual factors may play a major role on it
How are prognosis typically dictated?
Dictated a being either poor, guarded, good, or excellent
What does the P in the SOAPG note stand for and what is included in it?
P: plan
- It completes the PT plan of care (POC)
- May outline interventions to be included or included in the POC
- Includes duration and frequency of care
- May include referral to another provider
- Discharge planning
What does writing short and long term goals do?
- They help us direct interventions
- Measure effectiveness of interventions
- Communication of goals to other practitioners
- Value of care
____ are based on time frames based on prognosis, experience, or medical literature
Short and long term goals
SMART gives us structure for writing goals. What does SMART stand for?
- Specific
- Measurable
- Achievable through function
- Relevant/ patient centered
- Time-bound
What is a medical record?
Civilian or military documents that give information on the evaluation, findings, diagnosis, and treatment of a patient
What are included in medical records?
- Inpatient and Outpatient records
* Include, PT, OT, SLP, MD, Psych., etc.
What are the medical uses of medical records?
- A chronological record of medical care, to include the rationale upon which care is based
- A means of communication among medical personnel
- A basis for planning and continuity of care
- A basis for review, evaluation and study (continuous quality improvement activities)
- Data for medical research
What are the legal uses of medical records?
- Evidence to aid in proving that proper care was given should a malpractice claim arise
- Evidence of injury & disability for insurance, medical retirement, & civil litigation
- Evidence needed for criminal investigation
- Meets requirements set by external licensure and accreditation bodies
- Contains the medical history of Military Personnel
Medical records are the property of…?
Property healthcare provider, hospital, or patient depending on state
How are medical records stored?
- Electronic medical record (EMR) or electronic health record (EHR)
- Paper Chart
What form of storage is the affordable care act pushing towards?
Electronic medical record (EMR)
What are the contents of medical records in an outpatient setting?
• Physical examinations • Consent forms • Initial evaluation, follow-up, treatment and discharge notes • Immunization, laboratory and x-ray reports • Referrals to hospitals or clinics • Problem list (past medical history) • Discharge summary from hospital, etc.
What are the contents of medical records in an inpatient setting?
- Admission summary
- History & Physical (H&P)
- MD assessments and progress notes
- Nursing notes
- Lab & imaging reports
- Doctor’s orders
Medical records retention depends on the ___ and may differ if patient is an adult vs a minor
Medical records retention depends on the state and may differ if patient is an adult vs a minor
What does the Health Insurance Portability and Accountability Act of 1996(HIPAA) do for medical record privacy?
- Sets limits on how your health information can be used and shared with others
- Covers Individuals, organizations, and agencies that meet the definition of a covered entity
What is considered a covered entity?
An healthcare provider, health plan, healthcare clearing house
____ is classified as private information, meaning that information from them can be made available on a limited basis, such as for treatment and official purposes
Medical records
Who can look at medical records?
- Patient
- Medical personnel authorized to diagnose, assess, and treat
- Personal Representative- parent/guardian of minor, power of attorney
What is defensible documentation?
Specific guidelines for sound documentation
Why is defensible documentation important?
- Demonstrates compliance
- Historical account of patient/client encounters for potential legal situations
- Demonstrates appropriate services/reimbursement for many third party payers
What documentation guidelines (rules) for writing medical records?
- Use black ink.
- Place relevant patient statements in quotes.
- Enter only “facts”
- Use standard abbreviations.
- Date/Time all entries; if continued on a new page, re-enter date/time
and write (continued). - Use a name stamp or print your name beneath signature.
- Do not obliterate anything on the record; if a mistake is made, line out the incorrect entry without making it illegible; initial & date the deletion and then write in the correct data.
- Do not squeeze afterthoughts into the margins or space over the signature.
- Be complete, accurate, legible and informative.
- Use proper documentation format (Hx, PE, Dx, Px, Intervention) or local variation (ie SOAP, SOAPG)
- Note the date when documenting a return visit.
- Document missed appointments & other lack of patient compliance.
- Do not make uncomplimentary comments about a patient, a member of the patients family, or another health care provider (e.g. this patient is a crock, the doctor doesn’t know what he is talking about, etc)
ICD-10 provides….
Provides a diagnosis of diseases, disorders, and other health conditions
____ model describes a process of disability and focuses on the interrelationship of pathology, impairment, functional limitation, and disability
The Nagi model
_____ system focuses on human functioning. It provides a unified, standard language and
framework that describes how people with a health condition function in their daily lives rather than focusing
on a labeled diagnosis or the presence or absence of disease.
The ICF classification system focuses on human functioning. It provides a unified, standard language and
framework that describes how people with a health condition function in their daily lives rather than focusing
on a labeled diagnosis or the presence or absence of disease.
The____ uses a unique framework in which human functioning and disability are described as a dynamic interaction between various health conditions and environmental
and personal factors. It recognizes the impact of the environment on the person’s functioning.
The ICF model, uses a unique framework in which human functioning and disability are described as a dynamic interaction between various health conditions and environmental
and personal factors. It recognizes the impact of the environment on the person’s functioning.
What is the recommendation for selecting the right ICD code in order to bill for PT services?
select the most specific code that most accurately describes the condition you are treating based on the objective evidence.
What is the Current procedural terminology (CPT)?
The most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs.
When billing most third parties for services, it is necessary to utilize ___codes to describe the services that were rendered. Although CPT is not an exact description of physical therapists’ interventions, it does provide a reasonable framework for billing.
when billing most third parties for services…it is necessary to utilize CPT-4 codes to describe the services that were rendered. Although CPT is not an exact description of physical therapists’ interventions, it does provide a reasonable framework for billing.
___ includes all therapeutic services
Treatment
What are time based (constant attendant) CPT codes?
These codes allow for variable billing in 15-minute increments when a practitioner provides a patient with one-on-one services such as therapeutic exercise or manual therapy.
What are service based (supervised or untimed) CPT codes?
These are the codes therapists use to perform services such as conducting an evaluation or applying hot/cold packs. It doesn’t matter if you complete these types of treatments in 5 minutes or 45, because you can only bill for one code.
What is the most common claim form?
Universal Claim Form (CMS 1500)
What is one of the most important thing to do to support a billing process?
Create a defensible document
What does Locum tenens mean and what does it refer to?
Means placeholder and refers to a person who temporarily fulfills the duties of another.
Billing behaviors to avoid
- Billing for services furnished by aides or techs
- Submitting claims for services that you know are not reasonable and necessary
- Billing for excessive duration and frequency of services
- Billing under another rendering provider
