Physical Therapy Documentation- Final exam PTA 100
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27 Terms
What is the Nagi Model sequence?
Active pathology → impairment → functional limitation → disability
In the Nagi Model, what is disability?
Limitation in performing socially defined roles or tasks
What does ICF stand for?
International Classification of Functioning, Disability and Health
What are the two areas in ICF Part 1?
Body functions/structures + activities/participation
What are the two areas in ICF Part 2?
Environmental factors + personal factors
What is a major legal purpose of documentation?
Creates a legal record of care
What is a major communication purpose of documentation?
Communication between healthcare providers
What financial purpose does documentation serve?
Supports insurance reimbursement
What does "If it isn't documented, it didn't happen" mean?
The medical record is the evidence that care occurred
What must documentation demonstrate for skilled care?
Why skilled PT/PTA care is needed
When is PT no longer necessary?
Goals met, no longer benefiting, or services can be carried out through a HEP
What does POMR stand for?
Problem-Oriented Medical Record
How is a POMR organized?
Around the patient's individual problems
What does SOAP stand for?
Subjective, Objective, Assessment, Plan
SOAP: What is Subjective?
What the patient reports
SOAP: What is Objective?
Reproducible, verifiable information
What belongs in Objective?
Tests/measures and interventions
SOAP: What is Assessment?
The meaning of the Subjective and Objective information
What should Assessment show?
Response to treatment and progress toward goals
SOAP: What is Plan?
What happens next in the patient's care
What can the Plan include?
Future interventions, equipment, referrals, or discharge
Who must complete the initial evaluation?
PT
Who can complete daily notes?
PT or PTA
For a progress note, what can the PTA collect?
Subjective and Objective information
For a progress note, who should complete Assessment and Plan?
PT
Who completes the discharge summary?
PT
What is patient-first language?
Put the person before the condition or disability