Myers Lec 6 & 7, Documentation

Front 1

What is Documentation?

Back 1

It is a record of the care given & the quality of care.

Front 2

What are the 3 roles for documentation?

Back 2

1. Record of quality of care
2. Basis for reimbursement
3. Legal record

Front 3

Does Medicare pay for modalities? Like Ultrasound, hotpacks?

Back 3

No

Front 4

There are 6 different kinds of content that can be in PT documentation. What are they?

Back 4

1. Data: anything relevant to the pt information. both subjective & objective
2. The problem. This is not a MD dx, but a PT dx
3. Treatment plan
4. goals or outcomes
5. Record of the treatment
6. Treatment effectiveness

Front 5

What is the difference between an evaluation and an assessment?

Back 5

PT responsible for Eval
PTA responsible for assessments or progress notes

Evaluation is both the collection of data & the diagnostic part. The assessment is data collection

Front 6

What is SOMR?

Back 6

Source Oriented Medical Record: is when each discipline has its own area for its notes (MD, RN, PT, etc) all have their own section.

Front 7

What is POMR?

Back 7

Problem Oriented Medical Record: This note focuses on the pt problem and all disciplines wrote directly toward the problem list.

Front 8

What is a SOAP note?

Back 8

Subjective, Objective, Assessment, Plan.

Front 9

What do you put in the Subjective?

Back 9

Any info given by the patient, family, symptoms they are having, pain assessment, etc.

Front 10

What do you put in the Objective?

Back 10

Any data that can be reproduced or confirmed by someone else. Any treatment that was provided, and measurable assessements

Front 11

What is put in the Assessement portion of the SOAP note?

Back 11

This should answer the "so what". Document about safety, are they getting bettor or not, is treatment getting better or not. Interpret your data from the S&O. If you are giving me a one minute update, what would you tell me?

Front 12

What is in the Plan of the SOAP note?

Back 12

This is what you are going to do next time. How many visits are left, are you going to continue, add something else, do I need to talk to the PT, social worker? Is the pt going to by a walker? etc.

Front 13

Different ways to document

Back 13

NARRATIVE NOTE: This is a blank paper, you can write a paragraph out, or do a SOAP note.
COMPUTERIZED
DICTATION:
CHARTS/CHECKLISTS
LETTERS: We may need to write a letter to docs, lawyers, etc,
TELEPHONE: Anytime a pt says something pertinent on the phone, you need to get it into the chart. That includes email communication
IEPs & IHPs: Individual Education Plans (school setting) & Individual Habilitation Plan (for adults)
INSURANCE FORMS:

Front 14

Legal guidelines regarding documentation

Back 14

FREQUENCY: APTA recomends writing a note every time, but just not going to happen. In a skilled facility pt don't get better fast.
ACCURACY: Never make up data. Never record anything false, exaggerated. Never omit something even if it makes you look bad.
BRIEF: Thorough but brief
LEGIBILITY: Must be legible
SIGNATURES & CO-SIGNATURES: For medicare, initials & license # as well.
NO CHANGES: Never use pencil. Never erase. Anything you write is permanent.
TIMELY: Law notes must be timely

Front 15

What do you do if you make a mistake on your notes?

Back 15

Draw a single line through it and initial. then write correction.

Front 16

What is EHR?

Back 16

Electronic Health Records. Everyone will be moving to EHR

Front 17

What is "meaningful Use"?

Back 17

Meaningful use is the effective use of information to support better decision-making and more effective care processes that improve health outcomes and reduce cost growth.

Front 18

What are the three major goals for Meaningful Use?

Back 18

1. Data capture and data sharing
2. Support the development of advanced clinical processes
3. Improve healthcare outcomes

Front 19

What is EMR?

Back 19

Electronic Medical Record. This is the patient's data residing with one provider or facility

Front 20

What is PMR?

Back 20

Personal Medical Record: This is an internet-based tools for patients to access (part of) their health information and share it or use it as needed

Front 21

What is EHR?

Back 21

Electronic Health Record. This is the patient's EMR's plus PMR, in a central repository. Includes everything from multiple providers. This is yet to come....

Front 22

What is CDS and what does it do?

Back 22

Clinical Decision Support: It provides evidence-based knowledge related to pt specific data. Examples: Medication interactions, when to schedule age related tests, etc.

Front 23

What is CPOE?

Back 23

Computerized Provider Orders Entry. This allows orders for diagnostic & treatment services (such as medications, laboratory & other tests) to be entered electronically and processed automatically.

Front 24

What are 5 general topics that go in the objective section of a SOAP note?

Back 24

1. Results of measurements & tests
2. Description of pt's function
3. Description of treatment provided.
4: Objective observation of the pt
5. Record of the treatment sessions

Front 25

More on assessments

Back 25

Comment on safety, are goals being met, progression of treatment, precautions, reasons for remaining functional limitations, why skilled services continue to be needed, inconsistencies noted.) Setbacks should go here too!!! AVOID the “tolerated treatment well” assessment. The documentation books, PT’s and insurance companies hate this. It means nothing.

Front 26

More on Plan

Back 26

What is planned for the pt in the future. This has nothing to do with your therapists treatment plan or the POC because I’m not involved in that. This is MY plan of what I am going to do with the pt in the future. YOU can modify your treatments. What you might do at the next treatment session. Self reminders. “Need to practice stairs next time” It might be when the next treatment session is scheduled. What kind of PT consultation is needed “need to speak to PT regarding ulcer on foot”. If you’ve made comments on inconsistencies, what you are going to do about it. Any equipment or information you need for next session. We need to schedule a biodex test next time. Need to order a platform attachment for the walker next time.

P: Contact PT to ask if ice/heat modalities to be added to treatment plan for pain relief and circulation. Follow up with current exercises and prepare HEP sheets for 3 point gait training. Have patient obtain crutches. 2 visits left approved.