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DPT 713 Principles of Physical Assessment 3 > Documentation Formats > Flashcards

Flashcards in Documentation Formats Deck (10)
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1
Q

Narrative Note Writing

A
  • descriptive encounter with patient written in paragraph format
  • type of encounter: sequence of events/unusual incidents; conversations with HCPs, Pts, family members
  • pros: good for telephone conversations, detailed, comprehension, timeline aspect is good, liability purposes (litigation), paints vivid picture, helpful in detailing conversation, pediatric (read by laymen), puts jargon in context
  • con: not super efficient, less comprehensive, lack of organization, may omit items, variability
2
Q

SOAP Notes

A
  • provides structure to medical notes
  • S: what patient tells you
  • O: anything that can be measured
  • A: interpretation
  • P: what you’re going to do about it
  • S and O make up examination
  • A and P make up evaluation
  • PR: section is medical diagnosis, referral information, and medical record findings that precedes SOAP note in initial patient encounter
3
Q

Subjective

A
  • what is reported by patient/family-symptoms, complaints, contextual factors, personal goals, relevant medical history
  • not observed by therapist
  • ex: pain, changes, functional limitations, participation status
  • incorporating ICF model language into this model is a MUST: historically S heading associated with pain
  • comparison with patient client management model: heading-examination, subheading-history
4
Q

Objective

A
  • what can be measured: systems review, interventions provided, relevant tests and measures
  • examples that are ICF-based
  • comparison with ICF model: objective data-systems review, tests and measures
5
Q

Assessment

A

-interpretation of findings: relationship between impairments and function, problem list, rehab potential, PT diagnosis, prognosis, and dx goals, medical necessity
-initial documentation: relationship between impairments and activity limitations/participation restrictions
-interim: progress toward goals, summary of changes (daily note, reevaluation/reassessment)
=comparison to P/C managment: evaluation

6
Q

Plan

A
  • specific plan for patient management of PT-related problems
  • initial: medical necessity, referral justification, plan for patient/family education, plan for new intervention to be added, frequency, duration, amount of treatment
  • interim: plan for reassessment, change in POC
7
Q

SOAP Pitfalls: Subjective

A
  • too focused on pain, not enough emphasis on function

- solution: use activity limitations, participation restrictions and contextual factors as basis for taking history

8
Q

SOAP Pitfalls: Objective

A
  • written in terms of impairments only

- solution: find outcome measures that objectively describe participation

9
Q

SOAP Pitfalls: Assessment

A
  • written in term sof how patient tolerated treatment

- solution: describe relationship between pts impairments and improved function, with reference to objective data

10
Q

SOAP Pitfalls: Plan

A
  • to general: “continue per plan”
  • solution: what are you going to add, delete from POC? discuss patient education plans moving forward and what you plan to reassess next session