Week 2: Documentation/Soap Writing

studied byStudied by 38 people
5.0(2)
get a hint
hint

Patient Care Notes

1 / 39

Tags and Description

Health

40 Terms

1

Patient Care Notes

  • record what the therapist does to manage the individual patient's case

  • can be used in outcomes research

New cards
2

Disposition

  • last/present status of pt

  • after every session based on Sx. of pt

  • based on objective findings and response therapy

New cards
3

Initial Evaluation

initial note written after pt.'s first examination and evaluation, documents history, examination, evaluation, diagnosis, prognosis. and poc; need for pt's referral; goals, problem list.

New cards
4

Progress Notes

written periodically, recording results of examination and re-evaluation, changes in prognosis, poc as needed.

New cards
5

Discharge Notes

PT discontinued care, pt is discharged from therapy, after a final exam and evaluation is performed.

New cards
6

PT Notes

irregular documentation of pt's, in between sessions, documentation of what transpired during session, SOAP format, w/o history taking.

New cards
7

Subjective Objective Assessment Plan

SOAP

New cards
8

Subjective

includes CC of pt, HPI, Family Medical, Personal, and Environmental History.

New cards
9

Objective

results from pt.

New cards
10

Assessment

summary from subjective and objective parts.

New cards
11

Plan

what they need to do w/ pt. based on evaluation.

New cards
12

General Information

being taken bc it is needed for pt's demographic info/identifying information, can help identify what lead to that injury, etc.

New cards
13

Chief Complaint

  • should be specific area, pain scale, what type of pain, etc

  • PT should know what to do functionally, and what pt can't do functionally

New cards
14

Patient Goals

PT should know pt's goal.

New cards
15

History of Present Illness

details pt’s CC from w/c they are seeking medical attention as well as unrelated functional deficits, should explore other info related to CC such as recent and past medical/surgical history, complications of treatment, potential restrictions/precautions and mechanism of injury.

New cards
16

Ancillary Procedures

medical tests, results affecting pt’s condition or treatment ex: xray, mri, ct scan; aligned to pt’s condition, specific and sensitive to pt’s condition.

New cards
17

Medical/Drug History

drugs taken by pt in relation to injury, as well as supplements and maintenance drugs.

New cards
18

Past Medical History

present or recent diagnosis outside present injury.

New cards
19

Family History

hereditary diseases, sensitive to cases to systemic or neurologic in nature.

New cards
20

Personal, Social, and Environmental Hx

talks more about set up of pt.

New cards
21

Objective

  • results of tests and measures performed and the therapist's objective observations of the patient are recorded

  • measurable or observable information used to formulate the plan of care

  • repeatable

New cards
22

Examination

  • used to confirm or refute the suspected diagnosis, which is based on the history and observation

  • must be performed systematically with PT looking for a consistent pattern of S/Sx that lead to a differential diagnosis

New cards
23

Stereognosis

ability to recognize objects helped by the hand without vision.

New cards
24

Barognosis

ability to recognize weight.

New cards
25

Cadence

number of steps per minute.

New cards
26

PT Impression

contains the patient’s MD diagnosis, a summary of all the impairments listed in the O part, and its implication to the patient's level of function.

New cards
27

Problem List

  • a list of all the impairments noted in the observation section

  • list of complaints of the patient or the problems that you found in the assessment. This includes the subjective and objective measurements

New cards
28

Prognosis

include justification for further therapy for a patient who initially appears relatively independent with one functional activity as well as the projected level of improvement based on patient and case related factors./

New cards
29

Prognosticating Factors

basis how to determine the prognosis of the pt.

New cards
30

Positive Prognosticating Factors

facilitate patient's recovery.

New cards
31

Negative Prognosticating Factors

hinder patient's recovery and improvement even with therapy.

New cards
32

Long Term Goal

  • describes the final product to be achieved by therapy

  • these outcomes are listed in terms of function

New cards
33

Short Term

are interim goals that needs to be achieved to be able to achieve the long term goal.

New cards
34

AUDIENCE BEHAVIOR CONDITION DEGREE

ABCD of goal writing.

New cards
35

Audience

almost always, the patient is the audience. However, it can be a family member or the patient with family member.

New cards
36

Behavior

  • is always an action verb, often followed by the object of the behavior

  • the object of the behavior must be something that can be measured or described accurately so that you can document when these outcomes are achieved

New cards
37

Condition

includes the circumstances under which the behavior must be done or the conditions necessary for the behavior to occur.

New cards
38

Degree

  • it includes the minimal number

  • the percentage or proportion

  • any limitation or departure from a fixed standard

  • any distinguishing features of successful performance

  • this should be realistic, measurable, and observable in term of function

New cards
39

Specific Measurable Attainable Realistic Time Bound

a goal must be SMART

New cards
40

Plan

contains all the pt management as well as the time frame and schedule that the patient will be seen and treated.

New cards

Explore top notes

note Note
studied byStudied by 5 people
Updated ... ago
5.0 Stars(1)
note Note
studied byStudied by 180 people
Updated ... ago
4.8 Stars(4)
note Note
studied byStudied by 12 people
Updated ... ago
5.0 Stars(1)
note Note
studied byStudied by 90 people
Updated ... ago
5.0 Stars(2)
note Note
studied byStudied by 4 people
Updated ... ago
5.0 Stars(1)
note Note
studied byStudied by 31 people
Updated ... ago
5.0 Stars(1)
note Note
studied byStudied by 3 people
Updated ... ago
5.0 Stars(1)
note Note
studied byStudied by 117804 people
Updated ... ago
4.9 Stars(594)

Explore top flashcards

flashcards Flashcard48 terms
studied byStudied by 26 people
Updated ... ago
5.0 Stars(1)
flashcards Flashcard39 terms
studied byStudied by 4 people
Updated ... ago
5.0 Stars(1)
flashcards Flashcard55 terms
studied byStudied by 60 people
Updated ... ago
5.0 Stars(3)
flashcards Flashcard31 terms
studied byStudied by 3 people
Updated ... ago
5.0 Stars(1)
flashcards Flashcard66 terms
studied byStudied by 99 people
Updated ... ago
5.0 Stars(2)
flashcards Flashcard277 terms
studied byStudied by 29 people
Updated ... ago
5.0 Stars(1)
flashcards Flashcard535 terms
studied byStudied by 2 people
Updated ... ago
5.0 Stars(1)
flashcards Flashcard485 terms
studied byStudied by 238 people
Updated ... ago
5.0 Stars(2)