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Flashcards in Documentation and Medical Record Deck (25):
1

Why do we need documentation?

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

2

Reimbursement documentation

shows:
-PT decision making involved and reasons to do the interventions
-effectiveness of PT treatments
-treatments were cost effective and conducted by skilled practitioner
-THE NEED for Pt to be in PT

3

quality assurance documentation

define problems
outline POC
show barriers to recovery
tell goals for PT interventions
ensure therapist compliance, effectiveness
show progress and achievement of goals

4

continuity of care documentation

describe treatments performed
describe patient response to treatment
modifications to treatments

5

legal documentation

objective proof of PT care performed

6

research/education documentation

uses the objective info from documentation to advance the profession

7

marketing documentation

successful improvements of Pt's can be a good thing ;)

8

What does POMR stand for?

problem oriened medical record

9

What is POMR used for?

data, problem list, treatment plan, progress notes, discharge
helps communication between providers
helps to be better organized

10

What does SOMR stand for?

source oriented medical record

11

What is SOAP used for?

to separate sections for physician, nursing, pharmacy, dietary, PT, OT orders, test results etc
read through each section for information

12

What does SOAP stand for?

Subjective
Objective
Assessment
Plan

13

The Plan in SOAP?

future diagnostic or therapy or next therapy session

14

The Subjective in SOAP?

info given by pt or pt family/caregiver "PAIN" is here!!!!

15

The Objective in SOAP?

results o tests, measres and interventions, objective data

16

The Assessment in SOAP?

overall response to invterventions and the effects of intervention; changes in the pt's status, and the provider's input about the pt's progress

17

HPI stands for

History of Present Illness

18

PMHx

past medical history

19

PLOF stands for

prior level of functioning

20

Initial exam and eval contaings...

referral
HPI
PMHx
Med list
PT HPI and prior Hx
Diagnosis
Testing/imaging
eval data
PLOF
Treatment diagnosis
assessment including reason for skilled care
problems
POC

21

daily/weekly treatment notes

frequency/content dependent on practice setting, the pt type, and the payer involoved
includes pt full name, DOB, MR #, room #
SOAP or narrative

22

Progress notes involve

notes written by PT's to provide doc of continuum of care and justification of skilled PT services provided
explanations of the skilled interventions, complicating factors that affect the duration of skilled care
comparative data between initial eval and re-eval

23

Discharge report

Written by PT to provide the outcome of PT services provided
must include attendance/visits, current objective data, goals and dates goals achieved

24

Difference between sign and symptoms and where they belong in the SOAP note?

Sign - objective indication of something
(seen, heard, felt or measured)
Objective data
Symptom - a change in the body or its functions perceived by the pt
Subective

25

Assessment data

summary of data from S&O; patient response to treatment and progress toward goals