Prof Seminar II -- documentation (SOAP)

why do we document? give 3 important reasons

- legal reasons

- payment

- continuity of care

ABCs -- notes must be:

- Accurate

- Brief

- Clear

4 components of the Assessment

SOAP abbreviation

- subjective

- objective

- assessment

- plan

t/f: problem comes after subjective

false -- before

examination pt client management components (3)

- history

- systems review

- tests and measures

examination SOAP components (3)

- problem

- subjective

- objective

evaluation pt client management components (3)

- evaluation

- diagnosis

- prognosis

evaluation SOAP components (3)

- evaluation

- diagnosis

- prognosis

plan of care pt client management components (3)

- expected outcomes

- anticipated goals

- interventions

plan of care SOAP components (3)

- expected outcomes

- anticipated goals

- interventions

subjective components (add to anki)

quotes

subjective/history

cardiovascular, integumentary, musculoskeletal, neuromuscular, communication/language, affect, cognition, learning style, forms

systems review

put test and measures (objective) stuff into anki

3 components of assessment:

- evaluation

- diagnosis

- prognosis

part of the note that makes us a PT

assessment

summary statement of findings, including impairments, functional limitations (activity and participation restrictions), personal and environmental factors

evaluation

supports need for skilled intervention and further testing

evaluation

often portion of note read by insurers and other providers

evaluation

components of evaluation (4)

- impairments

- activity and participation restrictions

- personal factors

- environmental factors

relationship of impairments to functional restrictions and medical diagnosis, impact of restrictions on patient's life, compensatory concerns and effects of co-morbidities

diagnosis

"impaired balance"

"gross motor delay"

"abnormal posture"

PT diagnosis

prediction of level of improvement and amount of time needed for improvement

prognosis

factors that may affect the prognosis:

- motivation

- family support

- PMH

- co-morbidities

terms to use in the prognosis:

fair, good, poor, etc

short vs. long term

outcomes and goals

outcomes and goals should be (3):

- functional

- objective

- measurable

- who, what, how much, why (how will improve quality of life)

- audience, behavior, condition, degree

outcomes and goals

SMART (outcomes and goals) stands for

- specific

- measurable

- attainable

- realistic

- time-based

comes after goals

intervention plan

components of intervention plan:

- therapy setting/location

- frequency of visits

- length of therapy

- plans for further examination

- referral to other practitioners

- intervention - including progression

- pt education and equipment