Chapter 10 Flashcards
(32 cards)
The medical record contains:
- patient history
- current patient health problems
- interventions
- communications with patients and other provides
- billing records/ICD-10 codes
HIPAA
(Health Insurance Portability & Accountability Act)
- standard for privacy protection of health information
- applies to any group that maintains and transmits medical records in an electronic format
HIPAA penalties
- enforced by the Department of Health and Human Services Office of Civil Rights
- a patient has 180 days to report a violation
- may include up to 10 years in jail & up to $1.5 million for each incident
HIPAA guidelines
- personally identifiable information and personal health information must be protected
- patients have the right to review their medical records
- patient option of private treatment area
Documentation
Must demonstrate the patient’s need for skilled rehab services
- relates impairments to functional limitations
Impairments
loss or abnormality of musculoskeletal or other systems identified and measured by clinician
Functional Limitations
restriction or loss of ability to perform a certain task
Purpose of Documentation
- provision of an accurate medical record
- communication with referral source
- communication with coworkers
- communication with others involved with the patient
- protection from liability litigation
Initial Evaluation - Purpose
- introduce, describe, identify, and address the patients problem
- build rapport/trust
- introduce patient to rehab process
Initial Evaluation - Subjective
Patient interview
Includes:
- pain level
- onset
- MOI
- functional limitation
- complete medical history
- surgical history
- previous injury to same location
Initial Evaluation - Objective
quantifiable impairments measured and documented using a standardized, repeatable method in order to easily re-test to demonstrate progress in future visits
Initial Evaluation - Assessment
Contains:
- AT diagnosis
- impairments
- functional limitations
- prognosis
Initial Evaluation - Plan
Summary of the interventions needed to completely address the impairments and functional limitations listed in the assessment
Includes:
- treatment duration
- treatment frequency
- intervention list
- goals
Goal Writing
should relate an impairment to a functional limitation
includes:
- specific action to be performed by patient
- quantifiable, measurable, repeatable activity
- duration/reps of activity
- impairment that, if addressed, will allow the patient to perform the activities above
- functional limitation addressed
- timeline for goal
Common mistakes when writing goals
- no relationship stated between impairments and functional limitations
- no measurable outcome
- nonspecific task
- more than one measurable outcome
- nonspecific activuty
- non-descript word use
4 Levels of Function (goal writing) - Level One
the patient can perform basic ADLs without pain/symptoms, but cannot participate in recreational activities & has pain/symptoms with advanced ADLs
- goals that address endurance with daily & postural activities
4 Levels of Function (goal writing) - Level Two
the patient can perform all ADLs but has pain/symptoms DURING recreational activities
- consider higher-level household chores and high-level ADLs requiring endurance
4 Levels of Function (goal writing) - Level Three
the patient can perform all ADLs but has pain/symptoms AFTER recreational activities
- consider common functions in relation to how the patient can function once they are in pain after activity
4 Levels of Function (goal writing) - Level Four
the patient can perform ADLS & recreational activities without pain/symptoms
- when biomechanical deficiencies are present and function is likely to be hampered in the near future
- nothing abnormal during eval and no pain or functional deficiencies
Daily Notes
- every patient visit
- abbreviated SOAP note
- update physician/3rd party payers on progress
- refocuses future treatment
Daily Notes - Subjective
- pain scale
- changes in patient function
- patient comments
Daily Notes - Objective
- any reassessment performed
- treatments provided
Daily Notes - Assessment
- Patient response to treatment provided at visit
- progress made at visit
- problems encountered
- overall progress towards goal
Daily Notes - Plan
- changes in plan of care
- interventions to be performed at next visit
- assess goals
