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Who are some people that may read a patients PT record?
therapist, physician, insurance, lawyers, nurses, billing, social workers
Why would other professionals want to read a PT chart?
progress, see what has been done and who did it, measurements, treatments to do, precautions/restrictions, costs, health changes, why treatment is being done etc....
When documenting, who must the PTA keep in mind and why?
the reader (audience); readers are each interested in different pieces of information
Why is documentation significant?
evidence of patient care, accountability of patient care, importance of documentation
Documentation is written proof that what was given to the patient?
Under evidence of patient care, what is the "motto"?
"if it isnt written, it didnt happen"
Accountability of patient care hold who responsible for the care provided?
holds YOU (the provider of care) responsible
Accountability of patient care allows 3rd party payers what 3 things?
value of care provided, effectiveness of treatment, and medical necessity of the treatment
When documenting, what must you provide?
lots of details
What is the quality of physical therapy care?
care that follows the standards of practice for PT published by the APTA
Records of the quality of care allows for what?
communication between the medical team members
What 4 things are regarded during communication of a record of quality care for a patient?
- 1. identification of patients problem
- 2. solutions
- 3. plans for patients discharge
- 4. coordination of the continuum of care
What 3 reasons are medical records reviewed or audited?
- 1. quality assurance
- 2. research and education
- 3. reimbursement
Whos documentation standards and criteria should you follow?
the facility where you work
The documentation you make becomes a legal record, if called to testify in court, how do you want your documentation?
clear and accurate
What can be denied if documentation is not clear and provide rationale to support care provided?