PT410 9 P1 Documentation

Describe the 6 components of the patient/client management model

A. Examination - collect data
B. Evaluation - synthesize and analyze data
C. Diagnosis - process data and create outcome
D. Prognosis - create the optimal level of improvement
E. Interventions - interaction between PT and patient/caregivers
F. Outcomes

What are 3 sources of data collected during an examination?

• history
• system s review
• tests and measures

What are 3 different ways patient history can be obtained?

• chart review - typically in hospital
• intake form - typically in outpatient
• patient interview

What are 3 types of ways to communicate to a patient?

• oral
• written
• physical

What is the difference between an open-ended and close-ended question?

• open - can elaborate
• closed - confirm information gathered

What is a systems review?

brief or limited examination that can help report a patient as impaired or non-impaired

What are 3 cardiovascular/pulmonary measurements that would be taken during an examination?

• HR
• BP
• RR

List 3 observations that would be made to the skin during an examination

• skin integrity
• skin color
• skin texture

List 3 things that would be tested during an examination for the musculoskeletal system

• ROM
• strength
• symmetry

What does WNL stand for?

within normal limits

List 4 things that would be tested during an examination for the neuromuscular function

• coordination
• balance
• transfers
• locomotion

List 3 ways to describe the communication ability of a patient during an examination

• ability
• affect
• cognition

What type of data is collected during tests and measurements?

objective

What rules in or rules out causes of impairment and functional limitations?

tests and measures

What supports the therapist's clinical judgement?

tests and measures

When would you synthesize and analyze data collected to create a clinical judgement?

evaluation

List the 3 problems identified during an evaluation

• body structure or function impairment
• activity
• social participatoin

List the 3 things generated during an evaluation

• diagnosis
• prognosis
• plan of care

During which stage would you refer a patient if the condition is beyond PT?

evaluation

During what stage is the process and the outcome stated and there is an assignment of a concise level to the problem identified?

diagnosis

Describe 2 ways to assign a diagnosis

• ICD code - medical diagnosis
• physical therapy diagnosis - reduced force output, impaired balance, etc

List 2 things that the prognosis determines

• optimal level of improvement
• time necessary to achieve the projected outcome
aka goals

Describe a short-term, long-term, outcome, SMART, and ABCDFT goal

• short-term: intermediate goals to achieve long-term
• long-term: patient's condition at time of discharge
• outcome: optimal status for patient
• SMART: specific, measurablee, assignable, realistic, and time-bound
• ABCDFT: audience, behavior, conditions, degree, function, and time

List the 4 components of the plan of care

• overall goals
• interventions
• duration and frequency of service
• discharge plans

What is the intervention stage?

purposeful interactions between PT and patient/caregivers to achieve the goals

Describe the components of the FITT equation

• frequency: number of times per week and visits before a specific date
• intensity: amount of repetitions
• time: duration of daily session
• type: specific activity, posture, etc

List 3 purposes of documentaiton

• communicate with other professionals
• record of patient/client care
• research of outcome analysis

List 3 ways documentations serves as a record for patient/client care

• compliance with legal regulations (10 years)
• business record
• reimbursement (insurance)

List 4 types of documentation

• initial exam/evaluation
• visit/encounter
• re-examination
• dischage/discontinuation summary

List the 4 components of an initial exam/evaluation

• examination
• evaluation
• diagnosis
• prognosis (plan of care)

List the 3 components of a visit/encounter documentation

• interventions
• changes related to plan of care
• plan for next sessions

List the types of notes of a visit/encounter documentation

• daily note
• progress note
• documentation stating that the patient was a no show/cancellation

Which type of visit note can a PT and PTA authenticate?

daily

Which type of visit note must the PT sign off on if a PTA writes it?

progress

List 3 scenarios that a re-examination documentation would be needed

• unexpected progress
• has not responded to current treatment plan
• has new clinical findings

What is included in re-examination documentation?

data from repeated or new examination

What is the outcome of a re-examination?

modify or redirect intervention

List 4 components of a dischange/discontinuation summary

• current status of patient
• attainment of goals
• discharge prognosis
• future plans

List 4 components of a future plan

• education
• follow up care
• home exercise
• home environment

List 3 formats of documentation

• patient/client management model
• SOAP
• narrative

When will a SOAP note typically used?

for a daily session

List 3 things that are included in the subjective

• self report status/response to previous treatment
• goals of treatment
• results of self report tests and measures

List 5 things that are a part of the patient's self report

• history
• symptoms
• functional problems
• pain
• self report survey

List 4 things that are included in the objective

• verifiable data - from exam results
• objective observations by therapist
• treatment provided
• patient response to interventions

List 2 things that are in the assessment

• justification of problem list, diagnosis, and prognosis
• summary of the progress toward functional goals

What does the assessment portion of SOAP reflect?

PT's clinical decision

List 2 things included in a progress summary

• factors affecting the progress
• modifications of goals/treatment plan

List 4 things that are in the plan

• interventions - for upcoming sessions
• changes in the intervention strategy
• discharge plan
• home exercise program

List 6 essential components of documentation

• patient centered
• person-first language
• avoiding negative labeling
• avoiding subjective judgement
• avoiding derogatory statements
• precise and concise