Documentation and Medical Record

Question 1

Why do we need documentation?

Answer 1

reimbursement
assurance of quality care
assurance of continuity of care
legal reasons
research and education
marketing

Question 2

Reimbursement documentation

Answer 2

shows:
- PT decision making involved and reasons to do the interventions
- effectiveness of PT treatments
- treatments were cost effective and conducted by skilled practitioner
- THE NEED for Pt to be in PT

Question 3

quality assurance documentation

Answer 3

define problems
outline POC
show barriers to recovery
tell goals for PT interventions
ensure therapist compliance, effectiveness
show progress and achievement of goals

Question 4

continuity of care documentation

Answer 4

describe treatments performed
describe patient response to treatment
modifications to treatments

Question 5

legal documentation

Answer 5

objective proof of PT care performed

Question 6

research/education documentation

Answer 6

uses the objective info from documentation to advance the profession

Question 7

marketing documentation

Answer 7

successful improvements of Pt’s can be a good thing ;)

Question 8

What does POMR stand for?

Answer 8

problem oriened medical record

Question 9

What is POMR used for?

Answer 9

data, problem list, treatment plan, progress notes, discharge
helps communication between providers
helps to be better organized

Question 10

What does SOMR stand for?

Answer 10

source oriented medical record

Question 11

What is SOAP used for?

Answer 11

to separate sections for physician, nursing, pharmacy, dietary, PT, OT orders, test results etc
read through each section for information

Question 12

What does SOAP stand for?

Answer 12

Subjective
Objective
Assessment
Plan

Question 13

The Plan in SOAP?

Answer 13

future diagnostic or therapy or next therapy session

Question 14

The Subjective in SOAP?

Answer 14

info given by pt or pt family/caregiver “PAIN” is here!!!!

Question 15

The Objective in SOAP?

Answer 15

results o tests, measres and interventions, objective data

Question 16

The Assessment in SOAP?

Answer 16

overall response to invterventions and the effects of intervention; changes in the pt’s status, and the provider’s input about the pt’s progress

Question 17

HPI stands for

Answer 17

History of Present Illness

Question 18

PMHx

Answer 18

past medical history

Question 19

PLOF stands for

Answer 19

prior level of functioning

Question 20

Initial exam and eval contaings…

Answer 20

referral
HPI
PMHx
Med list
PT HPI and prior Hx
Diagnosis
Testing/imaging
eval data
PLOF
Treatment diagnosis
assessment including reason for skilled care
problems
POC

Question 21

daily/weekly treatment notes

Answer 21

frequency/content dependent on practice setting, the pt type, and the payer involoved
includes pt full name, DOB, MR #, room #
SOAP or narrative

Question 22

Progress notes involve

Answer 22

notes written by PT’s to provide doc of continuum of care and justification of skilled PT services provided
explanations of the skilled interventions, complicating factors that affect the duration of skilled care
comparative data between initial eval and re-eval

Question 23

Discharge report

Answer 23

Written by PT to provide the outcome of PT services provided

must include attendance/visits, current objective data, goals and dates goals achieved

Question 24

Difference between sign and symptoms and where they belong in the SOAP note?

Answer 24

Sign - objective indication of something
(seen, heard, felt or measured)
Objective data
Symptom - a change in the body or its functions perceived by the pt
Subective

Question 25

Assessment data

Answer 25

summary of data from S&O; patient response to treatment and progress toward goals