Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
13 Cards in this Set
- Front
- Back
|
treatment apporaches |
1-PT for strengthening/mobility 2-OT for positioning 3-dietary for nutrition 4-nursing for wound care 5-CNAs for proper skin care/checks |
|
|
HealthInsurance Portability and Accountability Act (HIPAA) |
-Passed in 1996 and enacted in 2002 |
|
|
The Medical Record is |
Legal}Confidential}Precise}Objective}Concise}Relevant}Legible}Thorough}Timed}Signed |
|
|
Skilled Nursing Facility Medical Chart is |
Source oriented}Divided into discipline specific sections}Inter disciplinary Care Plans/MDS avoid problem of limiting flow of care by combining disciplines/treatment strategies into different problems. |
|
|
SNFMedical Chart contains |
}Admission sheet with identifiers }HIPAAforms/consents }Advanced Directives }MDS/Careplans }History and Physical }Physician Orders }Physician Progress Notes }Nurses Notes }Admission Assessments } Labs } Therapy } RestorativeNursing } SocialServices } Dietary } Activities }Hospital Records |
|
|
Whatdo you look for in a chart |
}Diagnosis }Precautions and Protocols }Labs }NewOrders }PTevaluation/plan of care }Nursesnotes }MD progress notes |
|
|
APTA Defensible Documentation |
Services must be of such a level ofcomplexity and sophistication or the condition of the patient shall be suchthat the services required can be safely and efficiently performed ONLY by aqualified PT or PTA |
|
|
Red Flags |
-Incomplete documentation -Long treatment times with no justification -Lackof measurable, functional goals -Lackof functional progress |
|
|
Part B |
Students cannot treat a Medicare Part B patient. All student notes must be cosigned. PTAs can NOT complete the progress note (a PT must see the patient by a 10th visit and document progress/update goals), discharge summary or recertification. |
|
|
S: |
-make surethis section reflects the patient’s self reporting of status and response to previous treatments. -Ifthere are concerns/issues, make sure you document follow up! |
|
|
O: |
OBJECTIVE findings/ tests/measurements/ treatment rendered/treatment response |
|
|
A: |
clinical problem solving including professional assessment of patient’s progress/remaining functional limits and precautions. |
|
|
P: |
BE SPECIFIC/show (medical)necessity |
