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Intro To PT > Chapter 10 > Flashcards

Chapter 10 Flashcards

1
Q

What is documentation considered in PT?

A

-Foundation for communication between third-party payers and providers for PT services.

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2
Q

Why do we need physical therapy documentation?

A

-reimbursement
-assurance of continuity of care
-legal reasons
-research and education
-marketing

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3
Q

what needs to show on document to ensure reimbursement?

A

-that pt services were cost-effective and provided by a skilled practitioner

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4
Q

APTAs documentation guidelines

A

-must be consistent with APTAs standards of practice
-every visit/encounter requires documentation
-documentation must be legible and must use medically approved abbreviations and symbols
-black or blue ink
-electronic health records require security measures
-each intervention must be documented
-informed consents must be signed
-each document must be signed and dated by PTA/PT
-communications with other healthcare providers/professional must be recorded
-documentation of referral occur during initial visit
-cancellations and no shows must be documented

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5
Q

PT students notes should be co- signed by

A

-PT

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6
Q

PTA students notes should be co-signed by

A

-PTs/PTAs

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7
Q

Nonlicensed personnel’s notes should be cosigned by

A

-PT

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8
Q

2 types of medical records

A

1) Problem-orientated medical records
2) Source-orientated medical records

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9
Q

Problem-orientated medical records (POMR)

A

-Introduced in 1970s by Dr. Lawrence Weed
-method of establishing and maintaining the patients medical record so that problems are clearly listed in order of importance, and rational plan for dealing with them is stated.
-DATA IS KEPT IN FRONT OF CHART

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10
Q

Sections of POMR

A

-Data
-Problem list
-Intervention plan
-Progress note
-Discharge notes

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11
Q

POMR enhances…

A

-communication among healthcare providers
-organization and structure of medical info.
-chronological description of interventions
-specific plan to manage patients problems

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12
Q

Source oriented medical records

A

-Arranged in accordance with the medical services offered in the clinical facility.
-some hospitals use SOMRs by labeling a section in the chart for each discipline with a tab marker

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13
Q

1st section of SOMR

A

-physicians section followed by…
-nursing
-pharmacy
-dietary, ETC….

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14
Q

Criticization of SOMR

A

-it is difficult to read through each section for info.

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15
Q

SOAP format

A

-format used to write medical records
-created by Dr. Weed as a component of the POMR.
-each entry contains the date, patients identification number, and title of the patients particular problem, followed by SOAP headings

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16
Q

SOAP headings inlcude

A

-Subjective findings
-Objective findings
-Assessment
-Plan

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17
Q

Subjective findings

A

-about patient and their condition
-symptoms, complaints, goals, lifestyle, difficulties with HEP
-states, reports, says
-patient can be directly quoted

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18
Q

Objective findings

A

-written so reader can reproduce or continue intervention, or someone untrained in PT can see effectiveness of treatment.
-measurements, tests, SIGNS, interventions, observation of interventions, copies of HEP

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19
Q

assessment

A

-summary of objective and subjective part
-most important because it tells reader if PT is working
-included patients response to interventions, progress, or lack of towards goals

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20
Q

plan

A

-future tense
-plan for next section or how many are scheduled
-plan for reeval, introduction to new exercises, future doctor appointments

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21
Q

4 types of documentation reports in physical therapy

A

-initial evaluation report
-visit/encounter treatment notes
-progress reports
-discharge reports

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22
Q

Initial evaluation reports

A

-Foundation for all other reports
-establishes primary purpose for intervention and outlines the expectations for progress
-can be written in SOAP format, narrative, and another format

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23
Q

POMR focuses only on what…

A

-patients impairments and not functional limitations

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24
Q

Functional outcome report

A

-PTs prefer to use this for the initial examination
-includes reason for referral, patients functional limitations, PT assessment, functional outcome goals, and intervention plan.

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25
Why is FOR format becoming popular in PT?
-easily demonstrates the effect on impairments on functional limitations and it is relatively uncomplicated for reviewers.
26
Elements to a initial examination and evaluation report..
-referral -data accompanying referral -physical therapy history -referral diagnosis -prior therapy history -evaluation data -prior level of function -treatment diagnosis -assessment -problems -POC
27
Patient history
-part of the initial examination and evaluation -taken in orderly sequence
28
Elements of patients history
-Personal info. -medical diagnosis -patients chief complaints -patients present illness -onset of patients primary problems -patients past history -patients lifestyle
29
Visit/encounter Treatment notes
-Written by PTs/PTAs -typically short -can be written in SOAP format or narrative (SOAP USED MOST)
30
Treatment notes must include..
-patients full name -date of birth -medical records number -room number
31
Focus of progress notes
-on the reevaluation of problems identified in the initial evaluation or any new problems developed since last reevaluation
32
Progress notes must include these elements
-attendance -current baseline data -treatment diagnosis -assessment -POC
33
Discharge reports
-The last of the four types of reports used in physical therapy. -written by PT and describe success of physical therapy services
34
What kind of format is used most in physical therapy practice?
-SOAP -can be written daily or weekly
35
The soap format data can be used as follows:
-CAN BE WRITTEN BY PT/PTA 1)BY PT TO WRITE THE INITIAL EXAMINATION AND EVALUATION OF REPORTS -BY PT TO WRITE THE REEXAMINATION AND REEVALUATION PROGRESS REPORT -BY PT OR PTA TO WRITE THEIR VISIT/ENCOUNTER PROGRESS NOTE.
36
SOAP reexamination and reevaluation report
-written by PT periodically throughout the time of the patient is receiving physical therapy.
37
Symptoms
-subjective data in SOAP format reports -a change in the body or its functions perceived by the patient (includes date when symptoms occurred. location, manner in which they occurred).
38
EX of patients symptoms in PT
-pain -stiffness -weakness -numbness -loss of equalibrium
39
As per the Guide to Physical Therapist Practice, physical therapy diagnosis is..
-clinical classification by a PT of a patients impairments, functional limitations, and disabilities.
40
What kind of listening does a PTA use to only include relevant info. in the subjective section.
-active, directed, attentive, and exploratory listening.
41
Subjective data includes the following..
-patients complaints of pain -patients response to previous intervention -patients description of functional improvements -patients life-style situation -patients goals -patients compliance or difficulties with HEP.
42
Objective data in SOAP-format notes
-info that can be reproduced or confirmed by another healthcare provider with the same training as the one gathering the objective info.
43
Signs as objective data
-an objective evidence or a manifestation of an illness or disordered function of body. -apparent to observers, and symptoms are more apparent to patient/client. -can be seen, heard, measured, or felt by diagnostician
44
EX of sign in PT
-a patients gait pattern such as flexed posture and shuffling gait (PARKISONS DISEASE)
45
Why should the PTA write objective data of progress SOAP note so that...
-another PTA may reproduce or continue the intervention or.. -that a reader untrained in physical therapy (lawyer) may determine the effectiveness of treatment session
46
Objective section in progress SOAP note may contain the following..
-results of PT measurements and tests -description of interventions -description of patients function -PTAs objective observations of patient during interventions
47
Objective info. of the progress SOAP note must include:
-description of the reasons for intervention and intervention provided to patient -description of the patients response to each intervention -description of tests/measurements after interventions -utilization of words that describe the patient performing a function. -logical organization of information -utilization of words that portray skilled physical therapy services -inclusion of copies of additional written info. that was given to patient for home use.
48
Assessment of SOAP format note
-represents the summary of the info. from the subjective and objective sections of the SOAP note. -it tells the reader whether physical therapy is working or not
49
Assessment section contains the following
-patients overall response to intervention -patients progress toward short and long term goals -explanations as to why the interventions are necessary -effects of interventions on patients impairments and functional limitations -comparison of patients abilities from previous date to current one
50
Plan data of SOAP format-notes
P=plan -contains info. that the PTA may need to apply regarding the patients interventions before and during treatment sessions or in between sessions. -also indicated when next session will be. -uses verbs in future tense
51
Plan section may include the following
-Plan for next treatment session -plan for consultation with another discipline -frequency of treatment -plan for reevaluation or discharge by PT -Plan to discuss with the PT changes in the patients condition
52
Documentation guidelines should comply with..
-jurisdictional requirements -regulatory requirements -insurance company requirements
53
general guidelines that apply to physical therapy documentation are as follows:
-patients right to privacy -release of medical info. -all inquires for medical info. to the PTA should be directed to the supervising PT -written physical therapy records should be kept in a safe and secure place for 7 years.
54
When PTA verbally takes a telephone referral from another healthcare provider, the PTA needs to document in writing the following:
-date and time of phone call -name of person calling and name of healthcare provider who referred the patient -name of PTA who took the referral -date of when a written copy of the referral will be sent to PT office -name of PT who will be responsible for referred patient.
55
APTA recognizes the following preferred order
-PT/PTA -highest earned physical therapy-related degree -other earned academic degree -specialist certification credentials in alphabetical order -other credentials external to APTA -other certification or professional honors
56
Physical therapist professional education
-refer to the basic education of the PT to qualify him or her to practice physical therapy
57
physical therapist post-professional education
refer to the advanced physical therapy educational studies undertaken by a PT to enhance his or her professional skills/knowledge.
58
Defensible documentation
-intrinsic part of pt clinical practice -integrates latest evidence into practice
59
defensible documentation should include
-reflects PTs decision-making process -indicates evidence of the PTS unique body of knowledge and skill -provides the PTs verification of his or her judgment
60
APTA recommendation tips for documentation that reflects evidence-based care
-PTs should incorporate valid and reliable tests and measures -PTs and PTAs should keep up to date with current research -PTs should include standardized tests and measures in clinical documentation -PTs and PTAs should review and incorporate evidence-based interventions into clinical physical therapy.
61
computerized documentation
-rapidly becoming the norm -allows for point of service documentation
62
point of service documentation
-requires the PT/PTA to be adept at communicating with and attending to the patient while documenting patients responses, collecting objective data, monitoring exercise, or assessing progress.
63
benefits of computerized documentation
-submitting info. to insurance companies -monitoring clinicians productivity -tracking patients visits -easing patient scheduling -minimizing documentation paperwork -integrating billing -maximizing efficiency -increasing reimbursement -improved communication between healthcare teams

Intro To PT (25 decks)

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