Chapter 10 Documentation and the Medical Record Flashcards
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
