Flashcards in Week 5 Deck (60)
What is a SOAPG note?
It is intended to formulate organized medical record and align with patient/client management process
What is an initial evaluation?
The documentation of the first visit with a patient
What is progress note?
The formal reassessment of a patient
What is a daily note?
The documentation of the PT session
What is a discharge note?
Documentation performed when a patient is discharges from care
What does the S in the SOAPG note stand for, what is its intent?
- S: subjective
- Intent: assist practitioner with examination planning, setting goals, planning and response to treatment and patient compliance
What is included in the S in SOAPG note?
- Chief complaint (aggravation and easing factors)
- Contents from the subjective exam
- Functional status/activity level
- Can include direct patient quotes
What does the O in the SOAPG note stand for, what is its intent?
- O: objective
- Intent: Where results of tests, measures, and observations are recorded. Information from reassessment during treatment progression
What is included in the O in SOAPG note?
• Range of motion measurements
• Manual muscle testing grades
• Special tests
• Gait and/or transfer abilities
• Functional/Performance measures
• Interventions performed (in a daily note)
What does the A in the SOAPG note stand for, what is its intent?
- A: assessment
- Intent: capture the evaluation of the examination and/or progress through therapy
What is included in the A in SOAPG note?
• Functional deficits and/or impairments
• Disability levels
• Functional status/activity level
• Justification for further therapy
• PT diagnosis and prognosis
What is a PT diagnosis?
AKA: ICF model. Provides a rationale for the need to categorize function beyond a diagnostic category. Compliments ICD-10 coding
What does the ICF model of disability do?
- Helps us look at the health condition(disorder or disease)
- Looks at body function and structure
- Looks at the activity level of the patient
- Looks at how the patient participates within the level of their environment
- Looks at contextual factors
What are contextual factors?
Personal or environmental factors that can sometimes play into the patient's overall condition or prognosis.
What are body functions as it relates to the ICF?
Physiological functions of body systems (including psychological function)
What are body structures as it relates to the ICF?
Anatomical parts of the body such as organs, limbs and their components
What are impairments as it relates to the ICF?
Problems in body function or structure such as significant deviation or loss
What are activities as it relates to the ICF?
The execution of a task or action by an individual
What is participation as it relates to the ICF?
The involvement in a life situation
What are activity limitations as it relates to the ICF?
Difficulties an individual may have in executing activities
What are participation restrictions as it relates to the ICF?
Problems an individual may experience in involvement in life situations
What are environment factors as it relates to the ICF?
Make up the physical, social and attitudinal environment in which people live and conduct their lives
____ is determined following the PT diagnosis, are expectations for functional recovery/remedy for the patient's problem.
A prognosis is influenced by ___ and contextual factors may play a major role on it
A prognosis is influenced by *examination findings* and contextual factors may play a major role on it
How are prognosis typically dictated?
Dictated a being either poor, guarded, good, or excellent
What does the P in the SOAPG note stand for and what is included in it?
- It completes the PT plan of care (POC)
- May outline interventions to be included or included in the POC
- Includes duration and frequency of care
- May include referral to another provider
- Discharge planning
What does writing short and long term goals do?
- They help us direct interventions
- Measure effectiveness of interventions
- Communication of goals to other practitioners
- Value of care
____ are based on time frames based on prognosis, experience, or medical literature
Short and long term goals
SMART gives us structure for writing goals. What does SMART stand for?
- Achievable through function
- Relevant/ patient centered