Documentation

Question 1

SOAP

Answer 1

Subjective
Objective
Assessment
Plan of Care

Question 2

Subjective

Answer 2

Primary complaint
Activity and participation as identified by the patient
Reason for referral

Question 3

Objective

Answer 3

Qualitative and Quantitative
ROM, MMT, quality of movement, pain ratings
Innerventions

Question 4

Assessment

Answer 4

Impairment based diagnosis
Interpretation and summary of findings
Reports the need for skilled physical therapy intervention
Goals and prognosis

Question 5

Plan of Care

Answer 5

How often you will see them
What the patient will be doing
When a reassessment will reoccur
Communication of Care
Education
PT Interventions

Question 6

Goal of intervention

Answer 6

Impairment goals
Activity goals
Participation goals

Question 7

Goal of Prognosis

Answer 7

Timeline
ID contextual factors
Likelihood of acheiving goals of caree

Question 8

What is the purpose of documentation?

Answer 8

• Communitation tool for continuity of care (What exercises are they doing?, what are their symptoms like?, etc.)
• Clinical Decision Making
• Explain rationale for treatment
• Justify Skilled Care (PT vs others ex: OT)

Question 9

Types of Documentation

Answer 9

• Initial Evaluation
• Session Note
• Re-evaluation or progress note
• Re-evalutation without a scheduled follow up appt (discharge)

Question 10

Initial Evaluation

Answer 10

• Required at the onset
• Written by the PT
• Reason for Referral: Health Condition
• Goals of Intervention
• SOAP

Question 11

Session Note

Answer 11

• Written by a PT OR PTA
• SOAP

Question 12

Progress Note

Answer 12

• Written by PT
• SOAP
• Updates on impairments and activities
• Reexamination

Question 13

Progress note without a scheduled follow up (discharge)

Answer 13

• Written by PT
• SOAP
• Recommendation for home exercise program
• Plan to follow up with patient (You call to follow up or they call and update)

Question 14

Hand Written Documentation Requirements

Answer 14

• Must be black and blue ink
• Write legibly (Can be denied if not)
• Legal Doc must be able to defend what your write

Question 15

Two ways to document medical necessity

Answer 15

• Document functional regression has occurred (Ex: Knee Surgery)
• Document that without skille dintervention function will decline (Ex: Parkinsons)

Question 16

What makes PT “Skilled”

Answer 16

• We focus on activation, motion, etc.

Question 17

Patient Specific Functional Scale (PSFS)

Answer 17

• Self-reported, patient-specific outcome measure, designed to assess fucntional change
• Patient picks 3-7 areas of function
• Rate 1-10 scale and socre is added (1= unables and 10 = goal function)
• Easy to incorporate during initial evaluation and can be used as a functional outcome measure

Question 18

Payment and Coding include what two things?

Answer 18

Diagnosis - ICD-10 - Why they come to PT
Time spent with patient - CPT - Reimbursement

Question 19

What is it called when you go back and modify a note?

Answer 19

Addendum

Question 20

Audit

Answer 20

Detailed review of clinical records for evaluating quality of medical care

Question 21

Authentications

Answer 21

Identification of the author of the medical record and confirmation the contents are what the author intended

Question 22

Notice of Privacy Practicies (NPP)

Answer 22

Written document given to a health care consumer to explain privacy policies related to medical records

Question 23

Third-party payer

Answer 23

An org other than patient or health care provider that pays the bill

Question 24

Informed Consent

Answer 24

• Education of assessment or intervention
• Risk/Benefits
• Person has appropriate reasoning abilities
• Offer to awnser questions

Question 25

If a mishap occurs what do you do? (3)

Answer 25

- Document what lead to incident - Response to incident - Follow up with patient

Question 26

Recipe for an Assessment (4)

Answer 26

1. Summary/Introductory Statement 2. Diagnosis Statement 3. Need for Skilled Physical Therapy Services 4. Prognosis Statement

Question 27

Summary/Introductory Statement

Answer 27

- Patient age and any other descriptors necessary - Updated diagnosis/health condition and onset of symptoms - Pertinent Medical hostpry and OTHER health conditions that may effect PT care

Question 28

Diagnosis Statement

Answer 28

- Alternate to reffering dx and rationale - if needed - Sentence or bullet structure impairments - how impairments affect activity and participation restrictions

Question 29

Prognosis Statement

Answer 29

- ID contextual factors that may predict a favorable or not so favorable outcome of PT - What is the likelihood the patient will acheiev the goals of care