9/30a Documentation Basics (Integrated Care and Practice)

Question 1

why do physical therapists need documentation?

Answer 1

• to justify to insurance companies in writing why someone needs PT services
• Important part of tracking a patient’s progress
• If it wasn’t documented, it didn’t happen!
• If you don’t document, insurance doesn’t reimburse
• Communication with medical team is really through written documentation
• Helpful in legal situations
• CYA COVER YOUR ASS

Question 2

who are the different professionals that read notes?

Answer 2

-3rd party payers
-Physical Therapists
-Members of the medical team
Surgeons, Doctors, Nurses, OT, ST, Therapeutic Rec, PAS, Social Workers/case management
-managers (audits)
-Administrators (audits)
-researchers
-patients and their families

Question 3

charting errors

Answer 3

corrected by drawing a single line through the error and initialing and dating the chart or through the appropriate mechanism for electronic documentation that clearly indicates that a change was made without deletion of the original record.

Question 4

is documentation required for every PT visit?

Answer 4

YES

Question 5

when to use abbreviations as a PT?

Answer 5

Rarely, make sure that they are used facility wide and they won’t lead to any misunderstanding

Question 6

Skilled Service language

Answer 6

Services must not only be provided by qualified personnel but they must also require the expertise, knowledge, clinical decision making, and abilities of a physical therapist that others cannot provide.

Question 7

SOAP Notes

Answer 7

Framework for documentation
-Developed as part of a system for organizing the medical record
-used by many medical and healthcare professionals
S = subjective
O = objective
A = Assessment
P = Plan of Care

Question 8

Subjective note taking in SOAP

Answer 8

any information from the patient, family members, people providing care (try and make sure it comes directly from the patient)

• Anything about the treatment
• Anything about improvements
• Anything about complaints
• Patient’s goals
• Patient’s lifestyle or home situation

Question 9

Objective note taking in SOAP

Answer 9

information that you collect as PT through tests, measures, and skilled observation, no self report from patient alone…needs objective measures

• Patient Status
• Intervention
• Modalities Used
• Equipment Used
• Specific enough so anyone can repeat the intervention
• Tests and measures
• No Self Report

Question 10

Assessment note taking in SOAP

Answer 10

clinical reasoning, synthesis of objective data and subjective information to come up with what we think is impairing the individuals functional mobility/independence

• Thinking about how all of the pieces came together to make a decision
• Performed by the therapist following completion of the evaluation
• Important with ICF, how do these impairments translate to functional ability??

Question 11

Plan note taking in SOAP

Answer 11

specific info about future services you intend to provide including education for patient, patient family, and caregivers, anything you plan to change from the original

• The plan for the patient’s treatment
• All is linked to anticipated patient goals

Question 12

Patient Management Model for Note taking

Answer 12

Examination > Evaluation/Referral > Diagnosis & Prognosis > Visit Encounter/Progress Note > Reexamination > Discharge Summary

Question 13

Note taking in different parts of examination of patient management model

Answer 13

• Patient History
• Systems Review
• Tests and Measures

Question 14

Patient History

Answer 14

• General Health Status (self report, family report, caregiver report)
• Social/Health habits
• Family history
• Medical/surgical history
• Current conditions/Chief Complaint
• Functional Status and activity level
• Medications

Question 15

Systems review

Answer 15

• Cardiopulm: vitals, edema
• integumentary: gross range of motion, gross strength, gross symmetry and posture
• MSK: gross coordination, quality of movement, motor control/learning
• Documentation should include: communication, affect, cognition, learning barriers, education needs

Question 16

tests and measures

Answer 16

selected based on history and systems review

-don’t have to be an outcome measure. Some aren’t as detailed as studies

Question 17

evaluation

Answer 17

thought process that may not include formal documentation. Should lead to documentation of impairments, functional limitations, and disabilities using formats such as (use of all functions of the ICF)
-problem list should be generated
KEY FACTORS influencing patient/client status

Question 18

Diagnosis

Answer 18

documentation of a physical therapy diagnosis may include impairment and functional limitations.

**It is critical to understand how the diagnosis impacts the movement system even if it is given to you

Question 19

Prognosis

Answer 19

documentation of the prognosis is typically included in the plan of care.
Plan of care = general description of how things are going to be addressed
Anticipated discharge plan

Question 20

Visit encounter progress note

Answer 20

documentation of each visit shall include the following elements

• patient/client self report
• ID of specific interventions provided (frequency, intensity, duration, mode as appropriate)
• Changes in impairment, functional limitation, and disability status
• Response to interventions
• patient/client adherence to instructions
• communication/consultation
• documenting

Question 21

reexamination

Answer 21

documentation to re-examine the patient’s impairment, function, and/or disability status

Question 22

discharge/discontinuation summary

Answer 22

stop point at the end of POC, the goals that were reached and those that were not

Question 23

EMR

Answer 23

electronic medical record
increased portability of patient health information (PHI)
visible to outside institutions
modes will vary

Question 24

confidentiality

Answer 24

keep patient documentation secure
never leave charts unattended
follow HIPAA

Question 25

Defensible documentation elements

Answer 25

limit use of abbreviations date and sign all entries functional progress toward goals regularly document time of visit include all related communications include missed/cancelled visits demonstrate discharge planning t/o episode of care