Documentation Guidelines for MSK PT Flashcards
What is the purpose of documentation
- Gather pt info (S and O)
- interventions
- describe your assessments
- establish prognosis
- document your time
- track pts progression/regression
“if its not written down, it did not happen”
Who sees your documentaion
- other PTs
- MDs
- Medicare
- Insurance
- Attorneys
What are the different types
- initial eval
- daily notes
- progress notes
- D/C notes
- Notes to 3rd party payers
What makes initial evaluation (subjective)
- history
- pain
- aggravating/relieving
- PMH
- imaging/meds
- pt-rated outcome score
- pts goals
what makes up initial eval (objective
- impairments
- dx, guide treatment, important to assess treatment outcome
What makes up initial eval (assessment)
PT dx and need for PT
what makes up initial eval (plan)
- goals
- fx
What is the format of a daily note
SOAP note format
What are the components of daily note (subjective)
- pain
- Changes since last visit
- response to last visit
- HEP: completion rate, ability to reproduce with % of verbal cues
what are the components of daily note (objective)
- interventions (ex, manips, modalities, tapin/bracing)
- any impairments reassessed
- pt education
What are the components of a daily note (assessment)
- pts response to treatments
- why the pt needs skilled intervention
What makes up a daily note (Plan)
- continue PT
- interventions to add next visit
- fx
- RTMD
what makes up a progress note (subjective)
- pain
- overall; are you better or worse since start of PT
- primary cc
- changes since last visit? since starting PT?
- response to last visit
- aks or repeat pt rated outcomes
- HEP: completion rate, ability to reproduce with % of verbal cues required
What information would you put in the objective portion of a progress not
- reassessments but only for relevant measures to determine progression/regression of treatment
- documentation of any specific parameters for treatment
- Dc of any rx procedures that you were performing prior to this rx, with appropriate rationale
What makes up progress note (assessment)
- your assessment of pts progression/regression
- general health
- mental health
- function/disability: any change
