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S5 PTA Special Topics > Documentation > Flashcards

Flashcards in Documentation Deck (6)
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1
Q

Why document

A
  1. Communicate with other treating therapists
  2. Assistance with discharge planning
  3. Reimbursement
  4. Assistance with utilization review
  5. Legal document regarding the course of therapy for a patient
2
Q

Record

A

Progress notes and referrals

- departmental statistics and records are example of admin records

3
Q

Referral

A

Signed prescription form

  • must include name of patient and be signed and dated by referring physician
  • sometimes include number and frequency of treatments desired and any special precautions or instructions
4
Q

Progress notes

A
  • improvement of pt care
  • should contain pt ID, date, and therapist signature
  • should be written when pt’s condition changes during course of treatment
  • specific frequency of notes is dictated by department policy
5
Q

Discharge summary

A
  • usually conducted on last da of therapy
6
Q

10 tips for defensible documentation

A
  1. Limit abbrevs
  2. Date and sign all entries
  3. Document legibly
  4. Report progress towards goals regularly
  5. Document at the time of the visit (POS)
  6. Clearly identify note types (progress vs daily)
  7. Include all related communications
  8. Include missed or cancelled visits
  9. Demonstrate skilled care and medical necessity
  10. Demonstrate discharge planning though the episode of care