SOAPG Note, Goal Writing, Documentation/Med Recs

Question 1

Who introduced SOAP note?

Answer 1

Dr. Lawrence Weed

Question 2

What is the documentation of the first visit with a patient?

Answer 2

initial evaluation

Question 3

What is a formal reassessment of a patient?

Answer 3

progress note

Question 4

What is the documentation of a PT session?

Answer 4

daily note

Question 5

What is performed when patient is discharged from care?

Answer 5

discharge note

Question 6

What does the S in SOAP note stand for?

Answer 6

subjective

Question 7

What is included in the subjective examination note?

Answer 7

chief complaint, contents from sibjective exam, functional status/activity level. can include direct patient quotes

Question 8

What is the intent of the subjective note?

Answer 8

assist practitioner with exam planning, setting goals, planning and response to treatment, patient compliance

Question 9

What does the O in SOAP note stand for?

Answer 9

objective

Question 10

What is included in the objective portion of the SOAP note?

Answer 10

appearance, test results (ROM, MMT, special tests), vitals, gait/transfer abilities, functional/performance measures, interventions performed

Question 11

What is the intent of the objective portion of SOAP note?

Answer 11

record tests and measures and observations, information from reassessment during treatment progression

Question 12

What is the A in SOAP note?

Answer 12

assessment

Question 13

What is included in the assessment portion of SOAP note?

Answer 13

Functional deficits/impairments, disability levels, functional status/activity level, justification for further therapy, PT dx and px

Question 14

What is the intent of the assessment of SOAP note?

Answer 14

capture the evaluation of the examination and/or progress through therapy

Question 15

True/False: the PT diagnosis is the same as a medical diagnosis.

Answer 15

false

Question 16

What is the prognosis?

Answer 16

expectations for functional recovery/remedy of the patient’s problems, may be poor, guarded, fair, good, or excellent - influenced by exam findings or contextual factors

Question 17

What is the P in SOAP note?

Answer 17

plan

Question 18

Describe the plan portion in the SOAP note.

Answer 18

completes the plan of care, may outline interventions, included duration and frequency of care, may include referral to another provider, discharge planning

Question 19

What provides the rationale for the need to categorize function beyond a diagnostic category?

Answer 19

ICF model

Question 20

Describe what the ICF model looks at.

Answer 20

Health condition, body functions/structure, activity level, participation in community, contextual factors (environmental factors, personal factors)

Question 21

The following is an example of what part of the SOAP note: “The patient states that his pain level is 10/10”.

Answer 21

subjective

Question 22

The following is an example of what part of the SOAP note: “The patient will receive treatment 1 time per week for 4-6 weeks consisting of motor control exercises, mobility interventions and aerobic exercises.”

Answer 22

plan

Question 23

The following is an example of what part of the SOAP note: “Clamshells: 2 sets of 15, 1 set of 10.”

Answer 23

objective

Question 24

What does the assessment part of the SOAP note function to do?

Answer 24

pull it all together (subjective +

objective + prognosis/diagnosis)

Question 25

The following is an example of what part of the SOAP note: "The patient presents with a chief complaint of low back pain that started 6 months ago insidiously."

Answer 25

subjective

Question 26

The following is an example of what part of the SOAP note: "Plantar flexion manual muscle test = 4/5."

Answer 26

objective

Question 27

"The patient will have >150 deg of shoulder flexion in order to reach into high cabinets" is an example of what?

Answer 27

Goal writing

Question 28

Medical diagnosis is billed using what?

Answer 28

ICD-10

Question 29

What is a procedure code used for billing of services?

Answer 29

CPT

Question 30

What are the medical uses of medical records?

Answer 30

chronological record of care, communication among HCPs, basis for planning and continuity of care, basis for review/eval/study, data for medical research

Question 31

What are the legal uses of medical records?

Answer 31

evidence for malpractice claim, evidence of injury/disability for insurance/ medical retirement/ civil litigation, evidence for criminal investigation, meets requirements set by external licensure and accreditation bodies

Question 32

Who has ownership of medical records?

Answer 32

healthcare provider/hospital/patient (depending on the state)

Question 33

True/False: medical records retention is equal across the nation.

Answer 33

false, differs by state

Question 34

What law set limits on how health information can be used and shared with others outside the covered entity (HCP, helath plan, heathcare clearing house)?

Answer 34

HIPAA (1996)

Question 35

Who is allowed to look at a medical record?

Answer 35

Patient (limited), medical personnel, personal reps (parent/guardian of minor, POA)

Question 36

What are the documentation rules? [13}

Answer 36

1. use black ink 2. place patient statements in quotes 3. enter only facts. 4. use standard abbreviations 5. date/time all entries 6. use name stamp or print beneath signature 7. do not obliterate errors - cross out and initial/date 8. do not squeeze afterthought in margins or space over signature 9. be complete, accurate, legible, and informative 10. use proper doc. format (Hx, PE, Dx, Px, Intervention) or local variation (SOAP, SOAPG) 11. note the date when documenting a return visit 12. document missed appts/lack of compliance 13. do not make uncomplimentary comments