Clinical Documentation final
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. What would you like to do?
What information is included under "Subjective?"
- Anything relevant stated by pt., their fam, caregiver or memeber of healthcare team:
- Prior level of function
- History of present problem
- Lifestyle or home situation
- Patient/family goals
- Any complaints
- Response to treatment
- Emotions/attitudes affecting present situation
What are some (3) benefits of open-ended questions?
- Most helpful for therapeutic communication
- Encourage pts to identify more of the problem
- Allow client to express their own thoughts and feelings
What information is included under "Objective?"
- Results of tests performed
- Treatment given to the pt
- Cognitive level of pt
- Observations made by PT(A)
- Record of Treatment sessions
- Description of the pt's function
What should be inculded under the description of the pt.'s function?
- Quality of movement
- Equipment needed
- Distances, heights, times
- Environmental conditions
- Level of assistance needed
- Purpose of the assistance
Define Functional Indepence Measures (FIM)
Level of assistance required for pt. to perform ADL
Describe the 7 levels of Functional Independent Measure (FIM)
- 7-Completely independent (I)
- 6-Modified independent (Mod I)
- 5-Stand by assistance, no physical contact (SBA)
- 4-Minimal assistance, <25% (Min A)
- 3-Moderate assistance, 26-50% (Mod A)
- 2-Maximal assistance, 51-75% (Max A)
- 1-Total assistance, >76% (TA)
What are general rules about objective information?
- Observations made by clinician and results of measurement
- Testing procedures that produces objective data must be measurable and reproducable
- Used to formulate the Plan of Care (POC) and demonstrate the need for skilled PT
What are some guidelines to keep in mind when writing subjective information?
- Keep it clear and concise
- It is helpful to create subcategories to stay organized
- It is sometimes best to quote pt. verbatim to illustrate confusion, loss of memory, denial, attitude, or use of abusive language
- It is appropriate to include information from pt.'s fam/caregiver
What are some guidelines to keep in mind when writing objective information?
- Should be organized and easty to read and find
- Use headings/categories pertinent to pt.'s deficits
- May be best to summarize in flow sheets or charts
- Used to show pt.'s improvement/progress or decline in status/ lack of progress
What is outlined in the two systems of documenting the assessment section of the SOAP note?
- System 1: problem list, LTGs, STGs, and summary
- System 2: PT Dx/problem, expected functional outcomes, anticipated goals, interpretation of data
- Problem list: List of the pt.'s major problems based on the subjective and objective info
- LTG: What is to be acheived with therapy for each problem
- STG: Interim steps to achieve the LTGs with the same components
- Summary: Opportunity to draw correlation between the subjective and objective parts of the note
-Expected Functional Outcomes
-Interpretation of data
- PT Dx: Consists of pt.'s impairment and functional limitations
- Expected Funciontal Outcomes: Broad statement that describes the functional abilities necessary for the pt. to no longer need PT
- Anticipated goals: Describe the changes & improvments necessary for the pt.'s function to improve
- Interpretation of Data: Information regarding pt.'s response to the treatment plan
What criteria must be included in any anticipated goal?
- measurable criteria
- expected change in function
- time period
What should be included in the Interpretation section of the SOAP note?
- Pt. progress
- Rx effectiveness
- Completion of goals set by the PT at initial eval.
- Changes recommended for the POC
- Goals completed during indivual treatment sessions
- Lack of progress or ineffectiveness of an intervention or the Rx plan
- Inconsistencies in the data
- Pt.'s tlerace to treatment
- Suggestion of further testing/Rx needed
What are guidelines to keep in mind when writing the assessment information?
- All comments must be supported by subjective and objective data
- Include comments about whether the pt. is accomplishing the funcitonal outcomes or goals
What should be included in the "Plan" section of a progress note?
- What will be done in the next session
- When the pt.'s next session is scheduled
- What PT consultation or involvement is needed or when the next supervisory visit will be made
- Equip. or info that needs to be ordered or prepared prior to next Rx session
- Number of sessions left before d/c
- Any consultation with another healthcare provider
- Anything pt. or caregiver may need to do prior to next Rx
What is the purpose of the "plan" section of the SOAP note?
- Describe what will happen between now and the next Rx session
- Serves as a reminder for the treating clinician
- Inform another clinician who may be treating the pt. at their next session what should be accomplished
- Demonstrate follow-through, quality continuum of care, and PT-PTA communication
What are general guidelines to keep in mind when documenting the "plan" section?
- PTA may not modify the POC w/o consulting PT
- As the pt.'s status changes and goals are met, the PT can change the POC based on the PTA's findings
- Use "Guide to PT practice" for treatment plan ideas
Define "pathology" as it pertains to the disablement model
Injury occuring at the cellular level; disruption/damage to the integrity of body structures
Define "impairment" as it pertains to the disablement model
- Abnormality at the tissue, organ, or body systems level & includes clinical signs/symptoms
- *PT diagnosis
Describe "Functional limitations" as it pertains to the disablement model
Attributes that refer to the whole person and are related to social roles and normal ADL for that person
Define "disability" as it pertains to the disablement model
Inability for the person to fulfill their desired or necessary social or personal roles
What are the 5 components of the problem oriented medical record (POMR)?
- Data base
- Problem list
- Treatment plans
- Progress notes
- Discharge notes
What are the 4 formats of documentation?
- Flow charts/checklist
What are the 4 primary concepts related to the disablement documentation model?
- Functional limitation
What are the 5 elements of the initial evaluation?
- Examination: Hx, systems reviews, tests & measures
- Evaluation: Assessement of data collected during exam to identify pertinent problems
- Diagnosis: The level of impairment and functional limitation
- Prognosis: Predicted level of improvement that might be attained through intervention and the amount of required to reach each level
- Plan of Care (POC): Goals, planned interventions, frequency, duration, and discharge
What are progress notes?
Completed by PT/PTA documenting the interventions or services provided and the current pt. status
What is included in progress/interim notes?
- Pt. self report
- Interventions provided (frequency, intensity, duration
- Equipment provided
- Changes in pt. status as it relates to the POC
- Adverse reactions to interventions
- Factors that modify frequency or intensity of intervention and progression toward goals (includes pt. adherence)
- Information given to pt./pt's fam/ providers/caregivers
- Interventions to take place during future sessions
Does a PT need to co-sign a PTA's progress note?
Describe a d/c eval
- Content that interprets test results and identifies the plans for pt. after d/c
- only written by PT
Describe a d/c summary
- Written when pt. Rx is discontinued and only summarizes the care given, pt. response, and objectively states the functional state of the pt. at d/c
- *No interpretation of data is made*
- written by PT or PTA
What are the 5 reasons for discharge?
- Anticipated goals and expected outcomes have been met.
- Pt., caregiver or guardian decline to continue Rx
- Pt./client has plateaued
- Financial/Ins. resources expended (most common)
- Pt. medical or psychological issues
What is the difference between a discharge eval. and a discharge summary?
Discharge evaulations include reasons for goals & outcomes not being met and the discharge plan related to the pt.'s continuing care (may only be written by PT.)
What are some things that may be included in a discharge plan?
- Home exercise program (HEP)
- Referrals for additional services
- Recommendations for follow-up PT
- Family and caregiver training
- Equipment needed
What are the documentation roles of the PTA?
- Assist PT in gathering subjective and objective data for re-evaluations
- Write progress notes
- Write D/C summaries (NOT D/C evaluations)
What would you like to do?
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