Evaluation/Diagnosis and Assessment

Question 1

Why is documentation important? (name at least 4 reasons)

Answer 1

1. to serve as a record of patient care
2. to convey our unique body of knowledge and our practice
3. to communicate among different providers
4. to be used for policy or research purposes
5. to reflect appropriate provision of care
6. to record the episode of care
7. to document care and instructions provided to the patient and their response to treatment
8. to document any communication with individuals involved in the care of the patient

Question 2

What is the primary reason for denial of insurance claims?

Answer 2

Documentation errors/problems (insufficient documentation)

Question 3

Name the 8 reasons for denials in regard to documentation

Answer 3

1. no documentation for DOS
2. incomplete documentation
3. abbreviations not understood
4. goals are not written as functional outcomes
5. medical necessity is not clearly identified
6. does not support billing/coding
7. does not demonstrate progress
8. does not demonstrate skilled care

Question 4

What is differential diagnosis?

Answer 4

a list of problems developed by the PT, which may include several conditions, that might explain the signs and symptoms

Question 5

What is the PTs diagnosis guided by?

Answer 5

patient/client responses to interventions

Question 6

What is especially important about a diagnosis?

Answer 6

the patient and appropriate caregivers must fully understand the diagnosis for PT to be successful

Question 7

Define medical diagnosis

Answer 7

the anatomic, biochemical, physiologic, or psychologic derangement

diagnosis –> the labeling pathology

Question 8

Define physical therapy diagnosis

Answer 8

names the primary dysfunction toward which the PT directs treatment

diagnosis –> planning treatment

Question 9

Define primary diagnosis

Answer 9

a condition established to be chiefly responsible for a patient to seek medical care

the reason they come to PT

Question 10

Define secondary diagnosis

Answer 10

any additional conditions that affect patient care

other conditions or co-morbidities

Question 11

During the assessment, what must the PT first determine?

Answer 11

1. if PT intervention is appropriate
2. if consultation with another HCP is required along with PT
3. If the patient needs to be referred to another HCP if PT is not appropriate

Question 12

What is the purpose of the assessment?

Answer 12

to interpret data from subjective and objective sections using sound clinical judgement