PT 7311 Final Exam Study Guide

Documentation and Communication

Changes; interventions; progression

Content for progress note.
- ____________________/updates in patient status during reporting period
- _____________________ received to date - may include attendance
- Response to PT, re-examination, using subjective and objective examination (often original measures)
- _______________________ /changes to goals/POC (more/less time, goals continue to be appropriate, addition of goals, discontinue of goals)
- Format often mirrors initial evaluation

Varies

Frequency for letter.

PT

Letter completed by...

Evaluation; referral

Content for letter after first visit.
Summary of ___________________ and POC sent to referral source; notify PCP about evaluation; request ____________________ to another service

Update; referral

content for letter during episode of care.

status ___, request for ___ (functions like a progress or re-eval report)

summary; discharge

content for letter after last visit.

__ of episode of care and __ recommnedation

care; share

Content for other uses of letter.
- Coordinate/____________________ care among disciplines
- Requests/___________________ information with equipment vendors, 3rd party payers (claims appeals, letters of medical necessity, etc.)

1x at last visit

frequency for discharge summary

1x at first visit

frequency for initial evaluation

PT or SPT

initial eval is completed by…

History; impairments; systems review; diagnosis; prognosis

Content for initial evaluation.
S: Reason for referral, current status/problem, __________________/PLOF
O: Including ___________________, functional limitations (activity restriction), ___________________
A: Evaluation, _____________________
P: Goals and _____________________ (expected outcomes) for an anticipated period of time

every visit

frequency for treatment/daily note

PT or PTA

treatment/daily note completed by…

Sets; HEP; plan of care; plan

Content for treatment/daily note.
S: Pt/caregiver reports
O: Interventions delivered at each visit
- Procedural (_______________, reps)
- Education (instruction, _________________)
- Coordination (plan or actual calls to other providers)
A: Pt's response to intervention, pt status, progression or variations of ___________________/factors that modified frequency/duration of treatment with rationale
P: __________________ for next visit

weekly/monthly

frequency of progress note

PT or PTA (cannot be sole author)

progress note completed by…

10th

progress note should be completed every __ visit for medicare patients

PT or PTA (however cannot be sole author)

discharge summary completed

referal; why; compliance

Content for discharge summary.
- Reasons for ____________________
- Patient status at time of discharge
- Goals met/progress towards goal (rationale as to reasons for achieving/not achieving)
- _____________________ patient is being discharged (ex: goals met, self-discharge, non-compliance, plateau in function)
- May include record of attendance, no shows, cancellations, and overall ____________________
- Recommendations for the next level of care or follow-up, equipment, needs, areas that continue to need to be addressed

problems; liability exposure

Indications for incident reports.
- Promote quality care
- Alert management to potential ____________________
- Protect facility/staff from _____________________
- Aid training to prevent future, similar incidents

date; type; condition

Content for incident reports.
- Subject demographics
- _______________ of incident
- _______________ of incident
- _______________ of subject
- Course of action take
- Witnesses, if any

Do not speculate as to why it happened and do not take responsibility or demonstrate guilt!

before; changes; subsitute

indications for informed consent.
- Legally and ethically required ___________________ examination and intervention
- Whenever intervention
plan substantially ___________________
- When a ____________________ provides healthcare (i.e., another PT, SPT)

Interventions; risks; alternatives; agreement or refusal

Content of informed consent.
- Evaluation findings, diagnosis, health problems
- Description of recommended _____________________
- _____________________ or possible harm/complications associated with interventions
- Expected benefits/goals of proposed interventions
- Reasonable _____________________ to recommended interventions
- Solicit and answer patient questions
- Document patient's ______________________

specific (S of SMART goals)

target behavior or activity, condition, content

Measurable (M of SMART goals)

Quantification of performance (timing, distance/amount, frequency).

Attainable (A of SMART goals)

Specification of support needed (people, aids).

Realistic/relevant (R of SMART goals)

Expected or anticipated goals that aligns with patients own desires/goals.

Times (T of SMART goals)

Anticipated length of time to reach goal (usually stated in days, weeks, or number of visits).

Actor (A of ABCDE)

The "Who" (usually the patient, may be caregiver or parent).

Behavior (B of ABCDE)

Target or activity.

Condition/circumstance (C of ABCDE)

Conditions, context needed.

Degree (D of ABCDE)

Quantity or quality of performance; assist level

Expected time frame (E of ABCDE)

Anticipated length of time to reach goal.

Patient-centered

Make certain the goal is ______________________:
- Ensure goal is meaningful to patient/caregiver.
- Ensure patient/caregiver is aware of goals.
- Make sure patient/caregiver is the "Who."

Able to

Outcomes vs. Processes of goals.
- Use "___________________" in goal prn.
- Ex: Pt will be instructed in TTWB with RW on tile and carpeted flooring in preparation of d/c to home. vs. Pt to demonstrate MOD I ambulation in home while maintaining TTWB with RW on tile and carpeted flooring without LOB and demonstrating good safety awareness in 2 weeks.
First phrase would be more appropriate for plan section!

Functional tasks; detail

Specific vs. General of goals.
- Use actions/_____________________ for the behavior.
- Describe action in _______________________, not just one word.
- Ex: Pt. will ↑ strength. vs. Pt will increase L anterior tibialis strength to 4+/5 in order to clear foot with left swing phase of gait in 4 weeks.

state

Observable and Measurable for goals.
- Can explicitly ______________________ test or measure used to assess goal attainment.
- Ex: Pt will improve gait speed. vs. Pt. will amb 150 m. during 2 min. Walk test with O2 saturation >90% on RA in 2 weeks.

Quality improvement; clinical research

Uses of EMR.
- Generate pt reports and documentation (discipline-specific and aggregate reports)
- Outcomes assessment/_______________________ (data re: to certain interventions/pt types/etc. reviewed, plan for improving outcomes, continually reassess)
- Management purposes (monitoring case mix, tracking payer sources, productivity standards)
- ______________________ (data collected uniformly, retrospective analysis easier)

Efficiency; multiple; accuracy; less

Advantages of EMR.
- Increased _____________________ - collect data 1x/used many
- Data can be routed to ______________________ forms/documents (i.e., PT eval, team report, POC, outcome report, etc.)
- "Real time" access to information (immediate, but must be finalized, not just "saved)
- Improved transfer of health information between HCP and across organizations
- Less redundancy (i.e., demographics auto populate)
- Improved _______________________ and legibility
- More consistent/standard collection of information
- ______________________ space needed for records storage

Expensive; buy in

Disadvantages of EMR.
- Initial cost, development time, and transition process can be ____________________/overwhelming
- Staff training and compliance (need staff to "____________________", be comfortable with technology)

Malpractice; disabilities; rights

Documentation may be used as substantive and objective evidence of care during ____________________ claims, to validate a patients _____________________, or protect patient's ______________________ (i.e., Advanced Directives, DNR)

Save; stickered

Entries in EMR vs. Hand-Written Documentation.

EMR: "______________________" every entry in electronic documentation (automatic date/time stamp).

Hand-Written: Every page should be clearly identifiable ("______________________" with patient identifiers or pre-printed)

N/T; NA or N/T

Blank lines/boxes in EMR vs. Hand-Written Documentation.

EMR: "____________________" if necessary; if not, blank boxes and lines do not appear in final document.

Hand-Written: Write on every line report/form, use ____________________ with explanation..

Automatic; back; front

Chronological order in EMR vs. Hand-Written Documentation.

EMR: ______________________

Hand-Written: Oldest notes in ____________________, newest notes in ______________________ to demonstrate that there's been no changes/tampering/late entries.

Date; time; 2

Addendum in EMR vs. Hand-Written Documentation.

EMR: _____________________ and ______________________ stamped electronically

Hand-Written: _______________________ dates and times (one for addendum, one for treatment/evaluation)

addendum; initial; black

Mistakes in EMR vs. Hand-Written Documentation.

EMR: Create _________________________

Hand-Written: Single line, _____________________, "error", date and time, ____________________ ink

PT, DPT, or SPT

Signing in EMR vs. Hand-Written Documentation.

It is the same! Your name, ________________________

Clinician; language barrier; participate

The front office staff may know if an interpreter is requested, but it is ultimately the _______________________ who should be setting this up as indicated. An interpreter should be used whenever the ________________________ is to a degree that a patient may not be able to comprehend or understand recommendations or _______________________ in care

libel

Written/traceable defamatory or blaming remarks or comments.

slander

Spoken defamatory or blaming remarks or comments.

HIPPA

Health Insurance Portability and Accountability Act of 1996.

Portability; protection

HIPAA allows for ______________________ of health insurance with job loss and ______________________ of covered entities (electronic)

privacy rule

US Dept HHS implemented _____________________ which encompasses all types of PHI (electronic, paper, oral) (2003).

notice of privacy policy (NPP)

- Explanation of privacy policies related to their records
- Patients must sign in receipt of NPP or if chooses to decline notice

medicare

Federal health insurance plan for >65 yo, some individuals with permanent disability, and patients with ESRD.

medicare part a

hospital insurance, SNF, hospice, home health → Diagnostic related group (DRG) - r/t hospital benefit only

medicare part b

Medical insurance - Outpatient services, medical supplies, preventative → Payment: Fee for service

medicare part c

medicare advantage plans

medicare part d

prescription drug coverage

medicaid

Health benefit for patients who meet certain financial requirements or permanent disability; administered by individual states, which establish eligibility criteria.

PT

Medical necessity for Medicare → Determined by evaluating _______________; PT is involved in care (PTA cannot do all treatments!)

specific

Reasonable and necessary for Medicare → Treatment is ____________________ to patient; frequency and duration are in accordance to standards of practice.

cannot

Skilled services for Medicare → ____________________ be provided by someone other than a licensed PT

30 days

For Medicare, initial certification must occur within _____________________ of initial eval.

90 days

for Medicare, recertification must occur every ______________________ after initial eval.

10th visit; 30 days

For Medicare, progress notes must occur every _______________________ or _______________________ (whichever comes first).

Outpatient; discharge summary

For Medicare, patient must be under care of physician on _______________________ basis and _______________________ is required at close of care.

ICD-10 codes

"Medical diagnosis" codes. Every referral from physician must have IDC-10 code.

medical; treatment

There are 2 ICD-10 codes per case → _____________________ diagnosis (per physician) and _____________________ diagnosis (per PT)

treatment diagnosis

PT’s treat the ___!

CPT codes

Treatment codes that provide a common language among providers.

<8 min

there are time-based and non-time based codes. __ is not a billiable unit

greater than/equal to

Total time (includes set-up and take-down time) ____________________ direct time (treatment time only)

1 unit

8-22 min

2 units

23-37 min

3 units

38-52 min

4 units

53-67 min

subjective

Includes history and review of systems.

objective

Systems review; data gathered during physical examination

assesment

Summary statement, PT diagnosis, prognosis, and plan of care (sometimes).

Summary statement

Brief description of patient status → gender, age, primary complaint or reason for referral, medical diagnosis, therapy practice setting

Plan of care

Goals, frequency/duration (may outline timeframe/date for re-eval; may include d/c plans if not part of assessment), detailed interventions, statement of pt's informed consent.

PT diagnosis

Process includes integrating and evaluating the data obtained during the subjective and objective to describe and analyze the cause of the problem; Label/product ID's the cause of the problem
Prognosis

process

Component of PT diagnosis that includes integrating and evaluating the data obtained during the subjective and objective to describe and analyze the cause of the problem

evaluate

PTs are responsible for utilizing the diagnostic process to _____________________ a patient even if they have been referred to you with a label determined by the physician

label/product

Component of PT diagnosis that ID's the cause of the problem

person who is deaf; lighting; professional; visual

Successful communication strategies when using an ASL interpreter.
- Look and speak directly to the _____________________ - do not use 3rd person language
- Interpreter positioning varies
- Speak in your normal tone, at your normal pace
- Offer presentation materials to the interpreter
- Remember ______________________
- Interpreters are working, not participants
- If you are unsure of the appropriate way to proceed in a particular situation, just ask - preferably the deaf person as they are the expert on their own life
- If you can sign, absolutely do so to communicate - but don't just sign random letters or words
- Interpreters are fallible - interpreters will work best as a team
- Hire ___________________ interpreters, not just someone who knows some sign
- While interpreters are an ally to the deaf community, interpreters are here for PTs too
- Use ______________________ medical aids
- Establish an effective communication office policy

written; distrust; expensive

Possible limitations when using an ASL interpreter.
- ASL interpreter cannot usually translate ___________________
- ___________________ in the interpreter
- PT may not get all the information possible when using an interpreter due to the translating between languages
- Interpreters are very ____________________ to provide

patient; poorer; trust; disuse

Reasons why not using an ASL interpreter could be harmful or detrimental to a patient.
- Lack of information given to __________________ about condition, treatment, plan of care
- Lack of information received by PT about condition, goals, activities, limitations
- ____________________ health outcomes for patient
- Lack of patient _____________________ in healthcare providers
- _____________________ of healthcare services in future

department (PT), pt case number, pt DOB

What do interpreters need to put on documentation?

subjective

You should document that an interpreter was used during the session right above or on first line of ________________________. You can also place on the sections where an interpreter was used. Make sure you use bold or italics!

Form of interpreter, their license number, and when the interpreter was used (e.g., Entire session was interpreted via Spanish video interpreter, license number 12345).

What do you need to document when an interpreter is used?

every note

If the pt does not want to use an interpreter, you must document refusal on _______________________:
"Interpreter was offered but pt declined" or "Pt's son was present for appointment. Interpreter was offered but pt requested son interpret instead".

assertive; time

Be _______________________ when you think an interpreter needs to be used (be aware of how specific you need the information be) and use _______________________ wisely (type as much as you can while they're interpreting).

IMIA; standards of practice

Define what it means to be "certified" in interpreting:
- Follow _________________________ Code of Ethics?
- National Council on Interpreting in Health Care (1994-present) wrote first __________________________ in 2005
- Certification Commission of Healthcare Interpreters (CCHI) or National Board of Certification for Medical Interpreters (NBCMI)