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175 Cards in this Set
- Front
- Back
- 3rd side (hint)
What is medical documentation? ***
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the notation of information in a medical chart
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What is medical documentation designed to do? ***
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give relevant information about
- a patient's illness/condition and - the treatments/services rendered |
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Documentation also provides ***
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- evidence of care
- mechanism through which healthcare professionals are held accountable |
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How did PTs administer treatment and document it prior to the 1960s? ***
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- the MD actually wrote out what treatment was to be given in the form of a prescription
- the PT functioned as a technician, administering the treatment and making brief documentation for the treatment |
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From the 1960s onward, how did physical therapy administration change? ***
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- open referral for evaluation and treatment (eval & tx--diagnose and devise tx plan)
- direct access - Medicare standards came into play for care and documentation - more emphasis placed on documentation ($ and Standards of Practice) - justification became increasingly important the treatment focus also shifted from reducing impairment to improving/restoring function |
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Why is documentation so important today? ***
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- provides the basis for reimbursement
- gives rationale for services provided - records the quality of care - provides legal proof care was given - protects providers - gives justification for payment from limited pool of funds |
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Documentation provides an avenue for communication between ***
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- PT and PTA
- other disciplines - provides continuous update of patient progress |
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Purpose of documentation ***
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- Evidence of (quality of) care provided
- Accountability and protection - Legal record - Basis for reimbursement for services - Determine efficacy of treatment - Provide rationale for treatment/services provided - Quality assurance - Enable communication (PT/PTA, PT/other providers) |
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Why may medical records be audited? ***
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- Quality assurance (federal/state government, professional associations, accreditation agencies, health care facilities)
- research and education - reimbursement |
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What three events influenced the evolution of PT/PTA responsibilities and the role of documentation?
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- changes in physician referrals
- enactment of Medicare - development of documentation classifications |
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Nagi Model of Disablement of 1969
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- pathology (MD dx) leads to
- impairment (loss or abnormality of a physiological, psychological, or anatomical structure or function) which leads to - functional limitation (restriction of the ability to perform an activity or taks in an efficient, typically expected, or competent manner) which leads to - disability (an inability to perform or a limitation in the performance of actions, tasks, and activities usually expected in specific social roles and physical environments) |
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For proper documentation to occur in the physical therapy field, what must be differentiated?
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function and impairment
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Who may audit the treatment record? ***
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- federal/state government agencies
- professional associations - accreditation agencies - health care facilities |
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Is the PTA's documentation in a patient's record considered a legal document? ***
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yes and it may be subpoenaed if needed
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What are the six content categories of documentation content? ***
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- problems requiring medical treatment
- data relevant to the patient's medical or physical therapy diagnosis - treatment plan or action(s) to address the problem(s) - goals or outcomes of the treatment plan - record of administration of the treatment plan - treatment effectiveness or results of the treatment plan SHE DEFINITELY SAID KNOW THESE!! |
problem
data plan goal treatment effectiveness |
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What constitutes problems requiring documentation? ***
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medical diagnosis
- systemic disorder or disease - made by an MD physical therapy diagnosis - impairments (signs and symptoms) - functional limitations (tasks and activities) - made by PT |
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What constitutes data relevant to the patient's medical or physical therapy? ***
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- subjective data from patient, caregiver, etc. (symptoms, complaints, personal information)
- objective data (signs, measurements, tests, observations) |
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What constitutes data relevant to the treatment plan? ***
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- strategies to resolve or minimize problems
- explanation to patient - informed consent |
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What are the targets of goals and outcomes of the treatment plan? ***
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- goals are directed at impairment (sometimes referred to as STG)
- outcomes are geared toward resolving or improving functional limitation (sometimes referred to as LTG) |
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What constitutes a record of administration of the treatment plan? ***
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proof that the treatment plan is being carried out (e.g., narration, flow chart, checklist)
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What data constitutes a record of treatment effectiveness or results of the treatment plan? ***
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- interpretation of patient response to treatment
- statement of whether or not goals have been met these are important to insurance companies (third-party payers), researchers, and auditors |
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In what formats is data recorded? ***
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- computerized - with preprogrammed statements or phrases
- flowcharts - check off to document care - letter - to apprise MD or other healthcare provider - IEP - teacher, PT, OT, SLP, psychologist follow federal guidelines - Cardex - used within a PT department, but not a part of the medical record - Medicare Forms - standardized (CMS-700/701) - Narrative - descriptive - Templates |
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What are some other content models of documentation? ***
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- SOAP
- DEP (data, evaluation, performance) - PSPG (problem, status, plan, goals) - PSP (problems, status, plan) - Narrative or paragraph BELIEVE SHE SAID FYI, BUT JIC!! |
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What forms the basis for PT documentation? ***
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- The Guide to Physical Therapy Practice
- Based on Nagi’s Disablement Model -- pathology -- impairment -- functional limitation -- disability |
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What is a pathology? ***
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- comes to PT as a medical diagnosis
- an interruption of normal processes, usually at CELLULAR level, usually reflected in medical diagnosis (a disease or condition; e.g., torn rotator cuff, L. shoulder; Parkinson’s disease; L. CVA; torn meniscus, R. knee) |
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What is an impairment? ***
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- a loss or abnormality of physiological, psychological or anatomical structure or function at the TISSUE, ORGAN, OR SYSTEM level
- abnormalities or dysfunctions of the bones, joints, ligaments, muscles, tendons, nerves and skin, or problems with movement resulting from a pathology in the brain, spinal cord, pulmonary, or cardiovascular systems (e.g., decreased flexibility L. shoulder; ST inflammation, pain, m. weakness, m. spasm, swelling, incoordination of LEs, trunk instability) |
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What is a functional limitation? ***
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restriction of ability to perform an activity or task in typically expected or competent manner; inability to function adequately in one's environment
- basis for determining outcomes toward which physical therapy treatments are directed (e.g., unable to lift overhead, unable to don shirt independently, inability to transfer ind. in/OOB, can only sit for 5 mins 2▫ pain) |
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What is a disability? ***
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inability to engage in age-specific or gender-specific roles in a social or physical environment
more broadly it is a general term that refers to any long- or short-term reduction of a person's activity as a result of an acute or chronic condition (e.g., unable to maintain full-time job, unable to live independently, unable to care for dependent children, not able to play soccer) NOTE how disability is dependent on the individual and the previous level of function (PLOF) |
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Contrast a medical diagnosis and a PT problem. ***
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- a systemic disease or disorder (pathology)
- left CVA; - comminuted fx R. femur; - R. rotator cuff tear) vs. - identification of pathokinesiologic problems associated with faulty biomechanical or neuromuscular action (impairments and functional limitations) - inability to sit upright secondary to right hemiplegia; - able to amb only 10 ft NWB with crutches 2▫ to pain and weakness; - unable to lift overhead 2▫ to RUE weakness and limited R. shoulder ROM) |
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Pathology, impairment, functional limitation, or disability? ***
- Osteoarthritis - Multiple Sclerosis - 2/5 strength of LUE - Unable to lift overhead - CVA - Can sit only 5 min. without pain - Emphysema |
- Osteoarthritis (pathology)
- Multiple Sclerosis (pathology) - 2/5 strength of LUE (impairment) - Unable to lift overhead (functional limitation) - CVA (pathology) - Can sit only 5 min. without pain (functional limitation) - Emphysema (pathology) |
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Pathology, impairment, functional limitation, or disability? ***
- Polio - Decreased sensation to light touch RUE - Unable to feed and groom self - Muscle spasm and tightness LB - Parkinson’s Disease - Limited L. shoulder ROM - Pain left side neck 6/10 |
- Polio (pathology)
- Decreased sensation to light touch RUE (impairment) - Unable to feed and groom self (functional limitation) - Muscle spasm and tightness LB (impairment) - Parkinson’s Disease (pathology) - Limited L. shoulder ROM (impairment) - Pain left side neck 6/10 (impairment) |
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Pathology, impairment, functional limitation, or disability? ***
- Unable to work FT - Myocardial Infarct - Unstable gait - Deficit of 20% shoulder ROM - Poor strength of RLE - Inability to amb to BR ind |
- Unable to work FT (disability)
- Myocardial Infarct (pathology) - Unstable gait (impairment) - Deficit of 20% shoulder ROM (impairment) - Poor strength of RLE (impairment) - Inability to amb to BR ind (functional limitation) |
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What is informed consent? ***
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- all aspects of the treatment plan, including the purposes, procedures, expected results, and any possible risks or side effects, must be explained to patient and significant others
- “a legal condition whereby a person can be said to have given consent based upon an appreciation and understanding of the facts and implications of an action”. - the patient or his/her representative should agree to the treatment plan and procedures - collaboration |
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Four types of notes ***
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- initial evaluation
- progress - re-evaluation - discharge |
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What information is included in an initial evaluation? ***
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- general information about pt.
- subjective information (from the pt.) - objective information - measurements, tests - interpretation, PT dx, goals, expected outcomes - treatment intervention |
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What information is included in a re-evaluation? ***
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- summary of intervention
- subjective information - objective information - repeat measurements - effectiveness of plan - treatment plan |
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What information is included in a progress note? ***
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- usually completed after each tx session
- outlines tx given - pt response to tx (in brief) (every time patient is seen) |
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What information is included in a discharge note? ***
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- summary of tx provided
- subjective - objective - whether goals were met; how much - plans after D/C Note: Per TX rules, PTA can administer and document the last treatment, but for it to be called a discharge note, the PT must put in assessment and sign it, and is ultimately responsible for it. |
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What is the ABC of documentation? ***
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- accuracy (be true, don't omit)
- brevity (short and concise; careful use of abbreviations) - clarity (make your point clearly and legibly; correct grammar/spelling; incomplete sentences) |
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Other criteria for proper documentation? ***
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- patient name on each page
- supervising PT's name - date and sign all entries - if student, note must be cosigned by PTA or PT - use non-erasable black or blue ink - correct mistakes properly - don't leave empty spaces |
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Requirements for documentation signatures ***
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- your name, SPTA
- supervising PT name on each note written by PTA - never make or sign an entry for someone - PT/PTA co-sign |
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What else must be done with all student notes? ***
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they must be cosigned by a PT/PTA (usually the clinical instructor)
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How are mistakes corrected in documentation? ***
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- draw one line through the mistake
- initial and date (APTA actually says "signature" and date) |
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What is the most important form of physical therapy documentation to follow?
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the one for the facility which employs you
it should encompass proper documentation for Medicare, Medicaid etc. |
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What is one problem with computerized documentation?
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it often has preprogrammed statements that can be combined to quickly compose the progress note
however, this may prevent the proper individualization of the documentation; documentation must clearly distinguish the patient |
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What is an IEP?
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an Individualized Education Plan that is drafted in accordance with the Individuals with Disabilities Education Act (IDEA)
outlines the plan and educational goals and objectives for the school year for public school students |
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What is a cardex?
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a 4 X 6 index card used to record goals and intervention plan in a PT department
in pencil; updates made by erasing and writing in new achievements |
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What forms are used by Medicare to document
- Medicare Plan of Treatment for Outpatient Rehabilitation? - Updated Plan of Progress for Rehabilitation? |
- CMS-700
- CMS-701 |
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Who may complete the CMS-700/701?
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only the PT
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How often are physical therapy services renewed or recertified for Medicare patients?
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every 30 days
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What are narrative notes used to document?
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- short treatment sessions
- interaction with other health-care providers responsible for the pt's care |
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What is a SOMR and how is it organized?
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- source-oriented medical record
- organized according to the medical services offered at the facility with a tab marker for each discipline |
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What is the disadvantage of a SOMR?
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it is time-consuming to read through each section to find necessary information
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When was the POMR introduced?
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in the 1970s
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What is a POMR and how is it organized?
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- problem-oriented medical record
- data is ordered around the identification and treatment of the patient's problems - database - problem list - treatment plans - progress notes - discharge notes |
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What is the advantage of the POMR?
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easier to find the data you're looking for
e.g., all problems identified and treated by each discipline are all in one place |
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What is a FOR?
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- functional outcome report
sections include - reason for referral - functional limitations - PT assessment - therapy problems - functional outcome goals - treatment plan and rationale |
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What is the most widely used type of documentation?
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SOAP note
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What are PLOF and CLOF?
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- prior level of function
- current level of function |
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What is the desired outcome of the physical therapy treatment?
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preventing or minimizing the severity of the disability or handicap
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Is the PTA an appropriate person to obtain the informed consent?
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no, because it involves reviewing the treatment plan with the patient
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How is informed consent recorded?
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by a signed form that is usually placed in the medical record
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What should be included in devising a plan directed toward specific functional outcomes?
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- input from the patient; the patient's expectations
the treatment needs to be meaningful to the patient |
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Everything done during a treatment session should be geared toward...
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improving or resolving the functional problem that brought the patient to physical therapy
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Types of information to record in a progress note
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- treatment provided
- patient's reaction to treatment - progress toward goals/outcomes - changes in patient conditions |
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What is the most important content in the medical record?
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treatment effectiveness
(describes whether or not goals were met, and demonstrates quality/efficacy of the medical care) |
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What are the five elements of patient/client management?
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- examination - gather subjective and objective data
- evaluation - interpretation of the results of testing and observation, and clinical judgment that determines the final three elements - diagnosis - process and end result of evaluating examination data - prognosis - judgment about the level of optimal improvement the patient may attain and amount of time needed to reach that level - intervention - skilled techniques and activities that make up the treatment plan (specific interventions, their frequency/duration, estimated time pt will need treatment) |
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What types of examinations and evaluations are required (at a minimum)?
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- initial examination and evaluation
and - discharge examination and evaluation |
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What comprises examination?
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- history
- systems review - tests and measures |
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What is the primary reason the patient seeks physical therapy?
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functional limitation
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What does the Guide to Physical Therapy Practice describe?
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- PTs and their roles in health care
- generally accepted elements of physical therapy patient/client management - types of tests and measurements used by PTs - types of interventions PTs use - anticipated goals of the interventions - expected outcomes of physical therapy patient/client management |
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What are preferred practice patterns?
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descriptions about common physical therapy management strategies for specific diagnostic groups that serve as a guide for the PT when planning comprehensive plans of care
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What is subjective data? ***
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RELEVANT information from the patient, significant other, family members, caregiver
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Examples of subjective data ***
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- RELEVANT medical history not previously reported
- lifestyle, home situation, work tasks, school needs, leisure activities - patient-reported emotions or attitudes - patient's personal goals (function) - chief complaints - patient response to treatment; comments regarding treatment - patient's description of functional level |
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List some verbs used to report subjective data ***
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- states
- says - reports - complains of (c/o) - expresses - describes - denies |
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If the subjective information is from other than the patient... ***
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the source needs to be indicated
(e.g., pt.'s caregiver states...) |
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Under what portion of the SOAP note is the patient's pain reported? ***
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patient's statement of pain is SUBJECTIVE
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How should documentation addressing patient-related information be noted?
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in "person-first language"
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What is included in the medical record of a patient receiving physical therapy services?
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- PT evaluation
- plan of care - SOAP notes |
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What communication responsibilities does the PTA have to the PT with regard to patient care?
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to communicate:
- need for changes in plan of care (whether due to the patient not meeting goals or the need to progress the patient) - need to develop discharge plan |
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Types of information the PTA should be listening for during treatment
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additional information not already included in the record that includes, but is not limited to:
- medical history (e.g., unmentioned allergy) - environment (e.g., bathroom configuration) - emotions or attitudes (e.g., doesn't want to play children's games) - goals or functional outcomes (e.g., more steps at vacation home) - unusual events or chief complaints (e.g., flu) - response to treatment (e.g., no longer waking at night due to pain) - level of functioning (e.g., now able to button shirt) |
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Discharge evaluation vs. discharge summary
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- Only PT may write discharge evaluation
- PTA may write a discharge summary that merely summarizes the treatment given, in which case the PT still needs to write a discharge evaluation - if a discharge summary is being used as a discharge evaluation, it must be written by the PT |
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In which elements of patient/client care may the PTA participate?
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- examination - data collection (measurements of girth, strength, etc.) and gathering of subjective information
and - intervention (treatment) |
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How can the reliability of tests and measures be increased?
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by having the same person do them each time
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What is the primary documentation responsibility of the PTA?
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recording progress or interim notes
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Types of subjective data
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information told to the healthcare provider, such as:
- patient's past medical history - symptoms or complaints that caused the patient to seek medical attention - factors that produced the symptoms - patient's functional and lifestyle needs - patient's goals or expectations about medical care |
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Objective information includes information that is ________ and ______ _______
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reproducible
readily demonstrable they can be reproduced by any medical professional with the same training as the one who first performed the examination |
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Why is the SOAP note criticized?
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because the critics think it focuses on the patient's impairments, implying that improvement in the impairments will improve the patient's functional abilities
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What is relevant information with regards to subjective data?
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data related to patient's
- problem - diagnosis - treatment session |
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Types of listening skills
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- analytic (listening for specific types of information)
- directed (listening to pt answers to questions) - attentive (listening for general information/the total picture) - exploratory (listening because of one's interest in subject) - appreciative (listening for aesthetic pleasure) - courteous (listening as a show of respect) - passive (listening by overhearing) |
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What are the types of listening pertinent to PTAs?
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- analytic (listening for specific types of information)
- directed (listening to pt answers to questions) - attentive (listening for general information/the total picture) - exploratory (listening because of one's interest in subject) |
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How can the organization of subjective information be enhanced?
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by placing it into subcategories
(e.g., complaints, history, environment, goals, functional outcomes, behavior, and pain) |
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Is a subjective entry required?
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only if there is an update of the previous information or relevant new information
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Why would you use direct patient quotes in the subjective portion of the progress note?
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if quoting makes the intent of the comment or relevance to the treatment clearer
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In what types of situations is it appropriate to use direct patient quotes in the subjective portion of a progress note?
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- to illustrate confusion or loss of memory (e.g., dementia)
- to illustrate denial - to illustrate patient's attitude toward therapy - to illustrate patient's use of abusive language |
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If subjective information is given by other than the patient, what should be noted?
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- state who supplied the information
- if others provide information because the patient is incapable, state the reason the patient couldn't communicate (e.g., pt is in coma) |
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What types of pain profiles are commonly used?
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- pain scales
- checklist - body drawings |
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What is most important to remember about recording subjective pain levels?
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consistency is essential
you cannot compare a pain scale result on one visit to a body drawing on another; use the same means of reporting each time |
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Pain scales, etc. provide an _______ method of reporting _______ data.
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- objective
- subjective |
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Why is consistent pain documentation important?
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it provides a clear picture or measurement of treatment effectiveness and helps ensure reimbursement by third-party payers
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When using a scale to measure pain, what else should be included in the subjective entry?
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the scale and its correlation
(e.g., VAS 0-10, 0=pain-free, 10=worst pain imaginable; or on an ascending scale of 0-10) |
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What is objective data? ***
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information that can be reproduced, confirmed, or observed by another professional with the same training (PTA or PT)
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What types of information constitute objective data? ***
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- objective observations
- measurements and tests - description of patient function - treatment provided - record of total number of treatment sessions |
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What are objective observations? ***
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visual and tactile observations that could be duplicated or confirmed by another PTA or PT
(e.g., erythema, swelling, posture, warmth of skin) |
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How are measurements and tests recorded as objective data? ***
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retesting what was initially evaluated
helpful to chart in a manner that shows change over time |
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What categories of information constitute patient function data? ***
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- functional skill(s) performed
- quality of movement - level of assistance required - functional balance grades - purpose of assistance - equipment used - quantities - environmental conditions - cognitive status or complicating factors |
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Objective data: information recorded as functional skills performed ***
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- ambulation
- transfers - stair climbing - lifting - sitting balance - standing - moving sit to stand or vice versa |
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Objective data: information recorded as quality of movement ***
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- speed
- body mechanics - pattern of weight bearing - smoothness of motion |
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Objective data: information recorded as level of assistance required ***
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- independent - needs no one present
- supervision - needs someone at arm’s length - close guarding - ready to assist, but not touching patient - contact guarding - hands on patient - minimum assistance - patient does most of the work - moderate assistance - patient does some of the work - maximum assistance - patient does none of the work - verbal cuing |
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Objective data: information recorded as functional balance grades ***
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- normal
- good - fair - poor |
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Objective data: information recorded as purpose of assistance ***
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- verbal cuing
- to guide walker |
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Objective data: information recorded as equipment needed ***
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- assistive devices
- ambulation aids - wheelchair (w/c) - orthotics - supports - railings |
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Objective data: information recorded as quantities ***
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- distance
- height - time - weight |
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Objective data: information recorded as environmental conditions ***
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- level surface
- ramp - carpeting - outside - low seat - dim light |
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Objective data: information recorded as cognitive status or complicating factors ***
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- patient understanding
- ability to follow directions - fainting easily - patient at risk for falls - patient requires BP monitoring |
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How is treatment provided recorded as objective data? ***
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treatment description
- modality - exercise - dose - repetitions - area treated - patient position - duration - rest breaks anything unique to treatment (e.g., required 4 HP covers, significant erythema after HP, SOB after amb w/walker) |
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Why is the record of total number of treatments recorded (as objective data)? ***
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- may be required by insurance
- to keep track of number of sessions authorized, number of sessions administered, and canceled/missed appointments and reason |
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Why and how is proof of necessity of physical therapy skill recorded (as objective data)? ***
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- to demonstrate the need for skilled care
- demonstrated through use of physical therapy terminology and statements unique to the field - reader should clearly understand that the interventions provided during the treatment session require the skills of a trained physical therapy provider (PT or PTA) |
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Three characteristics of objective data? ***
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- relevant
- written for HCP and others who may read the note (insurance personnel, lawyer, etc.) - written in 3rd person |
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Objective data must be described in terms of ______ _____ or ______
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functional movement
actions |
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Symptoms are recorded in the _______ section;
signs are recorded in the ______ section. |
subjective
objective |
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For what audience does the PTA write the objective section of the progress note?
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- another PTA (who may have to fill in if you are unable to report to work)
- a reader untrained in physical therapy (e.g., insurance representative, lawyer, etc.) who is determining the effectiveness of the treatment |
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When appropriate, the PTA should relate the objective data in the progress note to...
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the same information in the initial examination or in previous notes for comparison
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When observing that a patient's functional status has not changed with treatment, be sure...
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all methods for measuring change have been used (e.g., they may still need a cane for support, but can ambulate the same 50 feet in 1/3 less time)
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How is consistency ensured in objective measurements and testing?
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perform and document in the same manner as in the initial evaluation
- ensure you know exactly what to measure and on which side - if motion is being tested, is it active or passive? - position of patient - starting and ending points, boundaries, measurement points above and below the starting point - same scale (inches, degrees) as used in initial evaluation |
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What measurements and tests may PTAs perform?
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those for which they have been properly trained
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Where may interventions provided be recorded in the medical record?
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- in the progress note
- on a flow chart - on a separate form elsewhere in the medical record |
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What needs to be recorded for an intervention to be reproducible?
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- identification of modality, exercise, or activity
- dosage, number of repetitions, distance - identification of the exact piece of equipment, if applicable - settings of dials or programs on equipment - target tissue or treatment area - purpose of the treatment - patient positioning - duration, frequency, rest breaks - other information the therapist needs to be aware of that is outside standard procedure or protocol (e.g., cane adjusted to greater than height determined by standard procedure because the increased height provided greater comfort to patient) - anything unique to the treatment of that particular patient, such as complicating factors (e.g., having to take patient's pulse rate every 5 minutes) - also note patient's response to treatment |
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What should also be done if written instructions, such as a HEP, are provided to the patient?
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a copy should be included in the medical record
the fact that the information was given should also be recorded in the objective section |
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When the patient is taught something like exercises, posture, or body mechanics, what should be documented in the note?
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that the patient gave a correct return demonstration, or an incorrect return demonstration requiring further instructions, etc.
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What is the major mistake PTA students make in documenting objective data?
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focusing on what they did (instructed pt. in.....) rather than how the patient responded (pt. ambulated 50' CGA)
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Other mistakes commonly made by PTA students?
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rambling!
commenting in the assessment on something not mentioned elsewhere in the note (S and/or O); comment appears to "come out of nowhere" failing to mention the goals or provide any comments on whether the patient is accomplishing the outcomes or goals; students tend to focus on the data measuring the impairment severity and the treatment procedures |
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Objective data content must be relevant to:
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- the chief complaint
- the goals or functional outcomes - the reason for the provision of skilled physical therapy services |
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What is the purpose of assessment? ***
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- interpretation and significance of the subjective and objective data
- progress toward accomplishing goals (Lukan) - Is patient better, worse, same? How do we know? (Stetz) SHE SAID TO KNOW THIS! |
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Content of initial evaluation and interim evaluation by the PT ***
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- interpretation of signs, symptoms, test results, observations
- identification of “PT diagnosis” or problem(s) based on conclusion from the interpretation - identification of anticipated goals and expected functional outcomes |
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Composition of anticipated goals (a.k.a. STG) ***
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anticipated goals - changes in impairments necessary for the patient’s function to improve
(e.g., ↑strength, ↑ROM to WNL, improve sitting balance) STG may be used instead - steps to LTG - expected to be reached in short period of time - reset as pt. progresses - older terminology |
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Composition of expected functional outcomes (a.k.a. LTG) ***
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expected functional outcomes - functional abilities necessary for the patient to no longer need physical therapy (usually relate to PLOF)
(e.g., ambulating to BR Ind., lifting overhead using correct posture, can sit one hour periods without pain) LTG may be used instead - broad statement describing functional level pt. is expected to reach by D/C from that facility - older terminology |
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What should be included in goals and functional outcomes? ***
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- action or performance
- measurable criteria - time period |
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What data should be included in the assessment portion of the progress note? ***
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- result of tx. effectiveness
- summary/interpretation of S & O data - changes in impairment (strength, flexibility) - statement of pt. progress toward accomplishing outcomes and goals - lack of progress toward goals - inconsistency in the data (S and O don’t match, better one day, worse the next, etc.) - changes recommended to POC - can address patient's response today or progress over time ASSESSMENT MUST BE SUPPORTED BY S and/or O |
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Some assessment examples ***
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- pt. improving; VAS scores have gone from 7/10 to 3/10 this week.
- more improvement in pain with change from HP to CP per pt report. - no change in pt knee ROM this week. - though pt has high VAS score (10/10) he xfers on/off plinth w/apparent ease (shows conflict between S and O) - improving; edema down approx 1 cm. since IE - pt. achieved goal of ind amb in room - pt making slower progress than anticipated, achieving only one STG (decreased edema); STGs of increasing ROM and strength are not evident (lack of progress) - pt does not like the sensation of ES and would possibly benefit from US (patient's response) |
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Well-written assessment help achieve what two outcomes? ***
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- help reader understand the treatment
- increase likelihood of reimbursement |
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Explain the difference between an anticipated goal and the expected functional outcome. ***
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anticipated goals are changes in impairments necessary for the patient’s function to improve
expected functional outcomes are the functional abilities necessary for the patient to no longer need physical therapy (and are usually related to PLOF) |
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What is contained in the plan section? ***
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- plans for intervention as related to goals and expected functional outcomes
- frequency - duration e.g., “Tomorrow we will start ambulation.” |
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Criteria for plan content in the initial evaluation ***
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- treatment directed toward the physical therapy Dx
- treatment of impairments (e.g., strengthening exer., stretching) - training in functional tasks (e.g., gait training, ambulating) should include - frequency - duration - measurement criteria and time frame Goals of initial evaluation go in Assessment, but “We will progress to ambulation with cane as tolerated” in Plan |
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Criteria for plan content in the progress note ***
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use future tense and
- relate to goals - outline what will be done in future sessions - include pt/family education - state when PT consultation planned, (e.g., Re-eval) - list any equipment to be ordered - state what is to be done next session and when - add reminders - state need for consultation with other services |
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Examples of plan content in the progress note ***
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- con’t POC (when in doubt, use this)
- see 3X/wk for strengthening & endurance training - talk to PT re: possible use of night splints - remind pt to bring in his x-rays - pt to be seen 2 more sessions - will talk to PT about pt’s increased pain |
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How does good documentation support the medical necessity for physical therapy treatment? ***
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- notes document reasons for physical therapy services
- helps prove skilled services are necessary |
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All medical records and information about patients are _______. ***
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confidential
and require patient authorization for release of information, or that the individual seeking access be involved DIRECTLY in the patient's care this means you can't release information to spouse, son/daughter, other relatives, neighbors, and friends without consent |
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When should you give out information about the patient to others? ***
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NEVER, unless
- it is to those giving direct care to the patient - when patient has signed a release of information |
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May a referral for physical therapy be made verbally? ***
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yes, but the v.o. is typically followed up by written orders
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Factors to consider for informed consent ***
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- explanation (understandable)
- to patient or significant other - name of provider/credentials - risks and precautions - alternatives - expected benefits - responsibility of patient - opportunity for questions |
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What happens if once given the pertinent information the patient refuses to give consent to treatment? ***
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- patient does have right of refusal
- document the reason(s) - notify the PT |
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Technical specifications for documentation ***
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- use black or blue ink (non-erasable)
- do not erase - do not leave empty lines - for a mistake, cross it out, initial (APTA says sign), and date - for an addendum - current date, “Addendum to PT note dated___” “O: omission in pt treatment…” |
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What is an incident report? ***
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a written account of incidents such as:
- anything out of ordinary/inconsistent (e.g., pt shows up drunk) - accident - situation that could cause accident |
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Why are incident reports recorded? ***
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- risk management
- legal protection |
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Besides filling out an incident report, what should you do when an incident occurs during treatment? ***
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document it in the SOAP note
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What goes into the incident report? ***
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- who was involved (patient, employee, visitor)
- what happened (describe circumstances surrounding the incident using objective, factual information) - gather witnesses (eyewitnesses document; only 1 person writes it up, but lists all witnesses) example of form in appendix of book (actually it's on page 141-142) |
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How is the incident report handled? ***
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- follow facility procedures promptly
- adhere to time limitation (usu. 24 hours) - ensure followup - file separate from medical record |
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What is an episode of physical therapy care?
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all physical therapy services that are
- provided by a PT or under direction/supervision of a PT - provided in an unbroken sequence - related to the physical therapy interventions for a given condition or problem |
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What is the best measurement to ensure third-party reimbursement?
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a description of the (positive) change in function
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The PTA can set treatment session goals to
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serve as steps to accomplishing the anticipated goals set by the PT
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Coordination of the evaluation and the progress note provides
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written proof of the PT-PTA team approach to the patient's care, enabling the reader to determine the quality of care provided
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What is the most important section of the progress note? Why?
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interpretation of the data (treatment effectiveness)
because it tells the reader whether the physical therapy care is helping the patient |
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Contrast the PTA's assessment with the PTA's entries in the objective data regarding patient response.
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- the PTA's entries describing patient response in the assessment portion are describing the patient's response to the overall treatment plan
- the PTA's comments in the objective section regarding patient's response to treatment are describing the patient's response to each individual intervention |
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Any comment made by the PTA in the assessment section must be
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supported by data in the subjective and/or objective sections
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Treatment is directed toward the physical therapy diagnosis and includes what two parts?
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1) physical therapy activities or interventions that treat the impairments contributing to the patient's functional limitations
2) training in the functional tasks described in the goals and outcomes |
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What determines the type and frequency of physical therapy intervention?
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medical necessity
it should be "reasonable and necessary" |
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When is physical therapy considered a maintenance service and no longer "reasonable and necessary"?
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- when an adult patient does not show any progress
- when an adult patient has met the goals and objectives - when an adult patient has received the amount of physical therapy allowed by the paying entity |
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How does medical necessity and "reasonable and necessary" differ for pediatric patients?
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- maintenance therapy is not a deterrant
- several programs combine to provide coverage - birth to age 3 = early intervention - ages 3-21 = school system even if patient does not show improvement in function, services can still be provided if the PT determines they are needed |
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What are the only requirements for pediatric physical therapy through the school system?
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- access to the school
- ability to move safely in school environment |
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Requirements for protection of medical records
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- secure location (e.g., nurse's station)
- secure office with limited access records must be returned or passed to another authorized member, never left lying around unattended, especially near a copy machine |
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Where must discussion of a patient's condition take place?
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in private areas and only with the patient, caregivers, and those authorized to receive the information
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The health-care facility owns the medical record, but what are the patient's rights as to the record?
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the patient has the legal right to know what's in it, but must follow facility requirements to request access
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What is HIPAA?
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Health Insurance Portability and Accountability Act of 1996
or Standards for Privacy of Individually Identifiable Health Information |
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Can state regulations overrule HIPAA?
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yes, such as in cases of disease reporting
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