Clinical Documentation final
Card Set Information
Clinical Documentation final
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
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
Distances, heights, times
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)
25% (Min A)
3-Moderate assistance, 26-50% (Mod A)
2-Maximal assistance, 51-75% (Max A)
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?
expected change in function
What should be included in the Interpretation section of the SOAP note?
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?
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
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)?
What are the 4 formats of documentation?
What are the 4 primary concepts related to the disablement documentation model?
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
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
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)