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PT Screening > Documentation > Flashcards

Documentation Flashcards

1
Q

SOAP

A

Subjective
Objective
Assessment
Plan of Care

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2
Q

Subjective

A

Primary complaint
Activity and participation as identified by the patient
Reason for referral

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3
Q

Objective

A

Qualitative and Quantitative
ROM, MMT, quality of movement, pain ratings
Innerventions

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4
Q

Assessment

A

Impairment based diagnosis
Interpretation and summary of findings
Reports the need for skilled physical therapy intervention
Goals and prognosis

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5
Q

Plan of Care

A

How often you will see them
What the patient will be doing
When a reassessment will reoccur
Communication of Care
Education
PT Interventions

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6
Q

Goal of intervention

A

Impairment goals
Activity goals
Participation goals

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7
Q

Goal of Prognosis

A

Timeline
ID contextual factors
Likelihood of acheiving goals of caree

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8
Q

What is the purpose of documentation?

A
  • Communitation tool for continuity of care (What exercises are they doing?, what are their symptoms like?, etc.)
  • Clinical Decision Making
  • Explain rationale for treatment
  • Justify Skilled Care (PT vs others ex: OT)
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9
Q

Types of Documentation

A
  • Initial Evaluation
  • Session Note
  • Re-evaluation or progress note
  • Re-evalutation without a scheduled follow up appt (discharge)
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10
Q

Initial Evaluation

A
  • Required at the onset
  • Written by the PT
  • Reason for Referral: Health Condition
  • Goals of Intervention
  • SOAP
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11
Q

Session Note

A
  • Written by a PT OR PTA
  • SOAP
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12
Q

Progress Note

A
  • Written by PT
  • SOAP
  • Updates on impairments and activities
  • Reexamination
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13
Q

Progress note without a scheduled follow up (discharge)

A
  • Written by PT
  • SOAP
  • Recommendation for home exercise program
  • Plan to follow up with patient (You call to follow up or they call and update)
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14
Q

Hand Written Documentation Requirements

A
  • Must be black and blue ink
  • Write legibly (Can be denied if not)
  • Legal Doc must be able to defend what your write
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15
Q

Two ways to document medical necessity

A
  • Document functional regression has occurred (Ex: Knee Surgery)
  • Document that without skille dintervention function will decline (Ex: Parkinsons)
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16
Q

What makes PT “Skilled”

A
  • We focus on activation, motion, etc.
17
Q

Patient Specific Functional Scale (PSFS)

A
  • Self-reported, patient-specific outcome measure, designed to assess fucntional change
  • Patient picks 3-7 areas of function
  • Rate 1-10 scale and socre is added (1= unables and 10 = goal function)
  • Easy to incorporate during initial evaluation and can be used as a functional outcome measure
18
Q

Payment and Coding include what two things?

A

Diagnosis - ICD-10 - Why they come to PT
Time spent with patient - CPT - Reimbursement

19
Q

What is it called when you go back and modify a note?

A

Addendum

20
Q

Audit

A

Detailed review of clinical records for evaluating quality of medical care

21
Q

Authentications

A

Identification of the author of the medical record and confirmation the contents are what the author intended

22
Q

Notice of Privacy Practicies (NPP)

A

Written document given to a health care consumer to explain privacy policies related to medical records

23
Q

Third-party payer

A

An org other than patient or health care provider that pays the bill

24
Q

Informed Consent

A
  • Education of assessment or intervention
  • Risk/Benefits
  • Person has appropriate reasoning abilities
  • Offer to awnser questions
25
Q

If a mishap occurs what do you do? (3)

A
  • Document what lead to incident
  • Response to incident
  • Follow up with patient
26
Q

Recipe for an Assessment (4)

A
  1. Summary/Introductory Statement
  2. Diagnosis Statement
  3. Need for Skilled Physical Therapy Services
  4. Prognosis Statement
27
Q

Summary/Introductory Statement

A
  • Patient age and any other descriptors necessary
  • Updated diagnosis/health condition and onset of symptoms
  • Pertinent Medical hostpry and OTHER health conditions that may effect PT care
28
Q

Diagnosis Statement

A
  • Alternate to reffering dx and rationale - if needed
  • Sentence or bullet structure impairments
  • how impairments affect activity and participation restrictions
29
Q

Prognosis Statement

A
  • ID contextual factors that may predict a favorable or not so favorable outcome of PT
  • What is the likelihood the patient will acheiev the goals of care

PT Screening (21 decks)

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