Chapter 10 Documentation and the Medical Record Flashcards
(32 cards)
Medical Records
1•Reimbursement 2•Assurance of Quality Care 3•Continuity of Care 4•Liability/Legal Reasons 5•Research/Education 6•Marketing
Reimbursement
1•Documentation is the basis for reimbursement by 3rd Party Payers
2•Documentation should include:
1•Complete Tx, details, & rationale
2•Tx effectiveness, including improvements, especially with function
3•Evidence of skilled intervention
4•Outcome Assessments (standardized tests measuring specific functions)
5•In the future, these will result in payment incentives or penalties
Quality of Care
& Continuity of Care
-Legal and billing perspective: the only interventions provided to the patient are the those documented
1•If it was documented, it wasn’t done
2•Therapists are protected by complete, detailed documentation of tx, education, patient responses
Quality of Care
& Continuity of Care
•Evidence-Based Practice:
practice techniques found to be most effective, in part from documented tx/outcomes
Quality of Care
& Continuity of Care
•Marketing:
Review of records provides outcomes that can be advertised to show your clinic’s effectiveness
APTA Documentation Guidelines
1•Be consistent with state practice act
2•Every visit/encounter requires documentation (even cancellations/no-shows), patient’s name/ID number on each page
3•Written in black ink
4•Errors crossed out with single line, initialed/dated by PTA (first and last name, title (SPT, PTA, etc), license #-optional
5•Electronic medical records (EMR)- kept confidential
6•Informed Consent- must be signed by patient or guardian
7•All communications with other providers must be recorded
8•Co-signs Required: PTA by PT, PT students by PT, PTA student by PT or PTA, non-licensed personnel by PT
Types of Medical Records: POMR & SOMR
Problem-Oriented Medical Records (POMR)
1•Problems are listed in order of importance with Tx plan
2•Sections include Data, Problem List, Tx Plan, Progress notes, Discharge notes
3•Each discipline records in each section as needed
4•Benefits:
1•Enhances interdisciplinary communication
2•Chronological description of txs
3•Specific plan to manage problems
Types of Medical Records: POMR & SOMR
Source-Oriented Medical Record (SOMR)
1•Arranged by disciplines
2•Physician, nursing, pharmacy, PT, OT, etc
3•Can be more difficult to obtain overall picture
SOAP Notes
•Format used in POMR
S = Subjective: What someone says (patient, caregiver, other provider) O = Objective: Things done or observed, results of tests, findings, treatment details A = Assessment: Opinion/judgement on how Tx went, patient progress, etc P = Plan: What’s coming up, what’s next; next treatment, need for tests, etc
Types of Physical Therapy Documentation Reports
]1•Initial Examination/Evaluation Report
2•Visit/Encounter Notes
3•Progress Reports
4•Discharge Reports
Initial Eval:
first and foundational report
Initial Examination/Evaluation
1•SOAP format, narrative, Functional Outcome Report (FOR)- demonstrates effects of impairments on function
2•Reason for referral & requested Tx
Initial Examination/Evaluation
•Data from referral:
-primary and referral Dx, onset date, medical Hx, meds, complications, precautions, Prior PT
1•History (Hx), DOB, Age, Gender, Date, Primary complaint
2•Mechanism of injury, diagnostic imaging/testing
Initial Examination/Evaluation
•Evaluation Data:
-vital signs, A/PROM, strength, bed mobility, transfers, gait, wheelchair mobility, endurance, wound description, sensation, pain, edema, etc
1•Prior Level of Function (PLOF)
2•Problems, Treatment Dx and Px, Rehab Potential, Plan of Care (Tx plan, frequency, duration, Pt. Education, HEP, STG, LTG, goal dates)
PT vs. Medical Diagnosis
•Medical Dx:
-Pathology or Identification of the cause of a patient’s illness or discomfort determined by physician
PT vs. Medical Diagnosis
•PT Dx:
-Clinical classification by a PT of a patient’s impairments, functional limitations, and disabilities AND represents the data obtained by PT exam to determine the cause & nature of impairments/etc
1•often uses the International Classification of Impairments, Disability, and Handicaps (ICIDH)
•Examples: Medical Dx: Multiple Sclerosis,
PT Dx: Ataxic gait and frequent falling.
Patient History
Patient Hx: Part of Initial Eval, includes:
1•Age, gender, occupation
2•Complete Medical Hx with Dx & Precautions
3•Chief complaints
4•History of present and past illness with Sx description
5•Onset of problem with Tx rendered so far
6•Allergies
7•Current meds
8•Lifestyle & habits
9•Social, vocational, economic, & family history
Writing Notes
•Treatment Notes:
Written by PTs/PTAs
1•Describe Tx, are generally short
2•Can be written as SOAP notes or as narrative format notes
Writing Notes
•Progress Reports:
-Written by PTs (also called Re-evals)
1•Documentation for justifying continuation of Tx
2•Focus on re-evaluation of original problems and any new ones
3•Describes Tx since eval/re-eval, complications, assess progress
4•Includes attendance, current status with eval measurements, need for skilled care, problems, plan of care
5•Addresses goal achievement with rationale
Writing Notes
•Discharge Summary:
-Written by PTs
1•Describe the success of the Tx
2•Includes all the same as a Progress Report, but includes specific discharge plans in the POC
SOAP Note: Subjective Data
Subjective Data: Includes
1•Information about the patient/patient’s condition as verbally described by the patient/caregiver/provider
2•Pain, response to previous Tx, function & goal status, compliance or difficulties with Home Ex Program (HEP)
3•Chief Complaint and related information only
4•Use active verbs: “states” “reports” “says”
5•Pain information can be placed in Subj. or Obj. sections
•When using standardized pain assessment can be in objective or as given during patient Tx
-Can quote or paraphrase patient/caregiver
•Example: Patient states that she is able to use her wheelchair at home or “I can use my wheelchair in my home”
SOAP Note: Objective Data inludes
-Objective Data describes what is observed or performed
1•Tx info should be written in sufficient detail that another therapist could completely reproduce the exact Tx later
2•Written in language that untrained person (insurance rep or lawyer) could determine Tx effectiveness
3 •Includes:
1•Results of PT measurements/tests
2•Description of Tx provided
3•Patient education instruction provided, including HEP
4•Work with other healthcare providers (OT, ST, etc)
5•Description of patient’s functional mobility
6•Relevant things that are observed, including patient response to Tx
•Example: Pt. transferred to wc with min assist and propelled wc over level surfaces x 23’ independently with moderate SOB, hip flexor strength 4/5
SOAP Note: Assessment Data
- one of the most important sections, because it explains if PT is helping, a judgement call
1 •Involves discussion of items already present in S/O sections, all comments here should be supported by evidence in S & O
2•Discusses the effectiveness of Tx & pt responses
3•Discusses progress or lack of progress towards goals
4•Explanations of why Tx is or is not necessary
5•Avoid the phrase “tolerated tx well”!!
•Example: Strengthening exercises are effective with increased weight from 2 to 4 lbs/rep., MMT increased from 4-/5 to 4+/5.
SOAP Note: Plan Data
-Discusses plans for the next or future interventions.
1•Use verbs in the future tense
2•Recommendations for Tx for the next or future treatments, incl. D/C
3•Type of exercise & modality, co-tx or consult, discuss with PT changes in CC, Dx or POC
4•Reflects when/where or how many Tx sessions are planned
•Avoid phrase “continue with POC”!
•Example: Will perform gait training on stairs and balance ex next visit, will discuss with PT increased swelling in foot