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15 Cards in this Set
- Front
- Back
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Detailed overall management strategy for you as a PT to accomplish the goals |
Plan of Care |
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Coordination and communication of patient instruction and PT interventions |
Plan of Care |
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purposeful interaction of the physical therapist with an individual and, when appropriate, with other people involved in that individual's care to produce changes in the condition that are consistent with the diagnosis and prognosis. |
INTERVENTION |
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RELATIONSHIP to ANTICIPATED/STGs must be considered: |
• Each anticipated goal • The patient’s alloted time for therapy • The patient’s exercise tolerance level • The patient’s level of motivation to participate with therapy and improve his current functional status • The patient’s support system |
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COMPONENTS of POC MUST be included: MUST be included: |
• Type of therapy setting • Frequency of sessions • Anticipated length of rehabilitation
• Location of Treatment • Example
• Example |
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Information that we include under the Plan(Coordination/Communication) |
Interventions provided and the progression planned |
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• From TheraEx, modalities to self-care training/ADLs trainings• Documentation of intervention should flow logically and systematically based on relationship on the goals • Sometimes, we include rationale in documenting interventions |
Intervention |
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• Important component to 3rd party payers• Still you must base your interventions based on PT’s scope of practice |
Skilled Intervention |
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Information that we include under the Plan(Skilled Intervention) |
• Anticipated discharge location • Plans for further examination/re-examination • Referrals made to other services |
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The following are also frequently included in the Intervention Plan section: |
Patient-Related Instructions o Patient/Family education o Equipment |
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Writing the Intervention Plan |
• Modalities: o Which modality o Where o How long o Intensity o What position (one that is best, most comfortable) • Electrical stimulation: o type of current, intensity, type of contraction, where, time, position • Ambulation: o Distance o Level of assistance o Device(s) o Time it takes to travel that distance o Weight-bearing status o Type of gait pattern/gait deviations noted • Therapeutic Exercise: o Extremity or trunk o Types o Repetitions o Position o Equipment used o Modifications o Amount of resistance given (or weight used) o Done in which planes • Home programs (usually attached to D/C notes as part of medical record): o Brief goal/rationale statement o Illustrations o Position o Directions: keep language simple and in patient terms o Repetitions and times/day to be performed o Progression o Equipment o Precautions |
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ON DAILY NOTES |
•Not necessarily same format with P on IE • Typically short on detail or the current plan given for the day o May include specific plan for next visit |
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Plan should be revised as you re-evaluate and reexamine your patients |
Progress or Re-examination notes |
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When revision is necessary, document changes in Intervention along with the changes noted during reexamination, reevaluation, and the resetting of anticipated goals |
Progress or Re-examination notes |
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Summary of patient’s total course of skilled care |
o Frequency and total # of times patient was treated ○ Missed sessions with date(s) and reason(s) o Intervention patient received o Level of patient/caregiver’s functioning o Date of and where the patient was discharged o Any instruction for discharge ▪ Who was instructed ▪ Type of instruction ▪ What instruction was given o Reason for discharge/discontinuation of service o Recommendations for follow-up tx or care |
