Lecture 11 - Documentation

Question 1

T or F: too much time is dedicated to documentation

Answer 1

FALSE, too little time

Question 2

Purpose of documentation (6)

Answer 2

Pt. notes are considered legal documents
Method of communication btw therapists
Medicare/insurance reimbursement
Decisions to discharge (hospital)
Structure clinical decision making
Can be used for research

Question 3

T or F: documentation is often used to determine how much should be billed for a visit

Answer 3

TRUE

Question 4

Examples of uses of documentation by others

Answer 4

Make decisions about reimbursement
Decide discharge and future placement
Is used as a quality assurance tool
Is used as data for research on outcomes

Question 5

4 things about legal aspects

Answer 5

1. Handwritten entries should be legible and written in INK (black or blue)
2. All notes must be dated when written, no backdating
3. All notes must be signed, followed by the writer’s professional abbreviation
4. Use a single line through an error, and write initials near the crossed-out word. Include date and time of correction

Question 6

4 basic types of medical record documentation:

Answer 6

• The initial evaluation
• Daily or per session notes (on going)
• Re-examination or progress notes
• Discharge summary

Question 7

Completed at visit, care given
To document impairments and functional limitations
Identify “diagnosis”, cause of functional limitations
Set goals and timeline (anticipated)
Specify a plan of care

Answer 7

Initial evaluation

Question 8

Required for every visit encounter
States what the AT and patient have done, and why
Reports changes in patient/client status

Answer 8

Ongoing (daily) session

Question 9

Update of patient/client status
Restate the goals
State what was done and why (therapist and patient)
Provides effectiveness of intervention in achieving the goals
When indicated, revision of goals
States how much longer intervention is anticipated
Provides justification for continued services

Answer 9

Progress note

Question 10

Identifies criteria (met) or reason for discharge
Provides effectiveness and intervention summary on initial problem (meeting expected goals)
Outlines relevant recommendations for future

Answer 10

Discharge

Question 11

Types of format for documentation

Answer 11

• Narrative
• Problem-oriented medical record
• SOAP
• FOR (functional outcome report)

Question 12

Narrative format

Answer 12

Simple
Telling a story
Therapist derived outline
Specific info left to discretion of author

Question 13

Cons of narrative format

Answer 13

Prone to omissions
High variability
Difficult to read/follow

Question 14

POMR format

Answer 14

• Numbered list of patients problems
• When entering documentation, each professional refers to the number of the problem
• Produce a note using SOAP format

Question 15

SOAP format

Answer 15

Subjective, Objective, Assessment, Plan
- Popular, now not linked to POMR
- Widespread acceptance
- Familiarity with the format

Question 16

Subjective information (what you hear)

Answer 16

a. Patient’s description of his complaints, loss of
function, pain and date of onset.
b. Relevant data obtained from interview, including
patient’s self reported level of function
c. Patient’s home or work environment
d. Past medical history

Question 17

Objective information (what you observe and do-measure)

Answer 17

a. Portions of patient’s chart (might include a
summary of recent surgery, and referral, laboratory
reports or x-rays)
b. Results of your examination

Question 18

Assessment (what you think)

Answer 18

• Professional evaluation of overall impairments
  based on integration of the subjective and objective
  findings.
• Identify and interpret problems, relate to overall
  function.
• Patient’s specific response to intervention

Question 19

Plan (what you will do)

Answer 19

• What treatment is planned - continue or change
  treatment.
• Progression of the plan (short and long term goals).
• Education planned for patient/family.
• Frequency/duration of treatment.
• Follow-up; consultation with or referral to other
  professionals

Question 20

Pros of SOAP format

Answer 20

• Emphasizes clear, complete, and well-organized reporting of findings
• Natural progression from data collection to assessment to plan

Question 21

Cons of SOAP format

Answer 21

• Associated with an overly brief and concise style
• Extensive use of abbreviations and acronyms
• Often difficult for nonprofessionals to interpret

Question 22

FOR format

Answer 22

• increased emphasis on functional outcomes
• economics of health care
• document the ability to perform meaningful functional activities
• establishes the therapy rationale by linking impairments to the disability

Question 23

Documentation takes many forms: (7 examples)

Answer 23

Written reports
Standardized forms
Charts and graphs
Drawings
Photographs
Videotapes, audiotapes
Physical specimens

Question 24

Audience of documentation

Answer 24

Only other AT/PTs
Dr.s
Parents
Insurance

Question 25

3 goal types

Answer 25

Disability goals Functional goals Impairment goals

Question 26

Disability goals

Answer 26

Express the expected outcomes in terms of the specific roles that the patient wishes to be able to participate

Question 27

Functional goals

Answer 27

Express the expected outcomes in terms of the skills needed to participate in necessary or desired roles

Question 28

Impairment goals

Answer 28

Express the expected outcomes in terms of the specific impairments that contribute to the functional limitations

Question 29

Essential components of a well-written functional goal

Answer 29

Actor Behaviour Condition Degree Expected time

Question 30

Practice abbreviations at slides in ppt

Answer 30

53-54

Question 31

See slide 51 for 10 common charting mistakes

Answer 31

READ