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Introduction to Physical Therapy Documentation Questions and Answers £11.31
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Introduction to Physical Therapy Documentation Questions and Answers
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Introduction to Physical Therapy Documentation Questions and Answers Why do we document? 1. serves as a record of patient/client care including a report of the patients/client's status, physical therapy management, and outcome of physical therapy intervention 2. is a tool for the planning and pr...

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  • January 2, 2025
  • 5
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

Subjects

  • introduction to physical therapy documentation que
  • top 10 payer complaints about documentation reaso
  • things to avoid when documenting patientclient t

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Introduction to Physical Therapy
Documentation Questions and Answers
Why do we document? - answer 1. serves as a record of patient/client care including
a report of the patients/client's status, physical therapy management, and outcome of
physical therapy intervention
2. is a tool for the planning and provision of services, and is a communication vehicle
among providers
3. tells others about our abilities, our unique body of knowledge, and the services we
provide as PTs and PTAs
4. may be used to demonstrate compliance with federal, state, payer, and local
regulations
5. provides an historical account of patient/client encounters that can be used as
evidence in potential legal situations
6. May be used to demonstrate appropriate service utilization and reimbursement for
many third-party payers
7. may be used for policy or research purposeds including outcome analysis

top 10 payer complaints about documentation (reasons for denials) - answer poor
legibility
incomplete documentation
no documentation for date of service
abbreviations - too many, cannot understand
documentation does not support the billing (coding)
does not demonstrate skilled care
does not support medical necessity
does not demonstrate progress
repetitious daily notes showing no change in patient status
interventions with no clarification of time, frequency, duration

things to avoid when documenting - answer "Patient/client tolerated treatment well"
"continue per plan"
"as above"
"unknown/confusing abbreviation" - use abbreviations sparingly

VC - answer vital capacity

MMT - answer manual muscle testing

WBAT - answer weight bearing as tolerated

PLOF - answer prior level of function

, WNL - answer within normal limits

WFL - answer within functional limits

general guidelines - answer documentation is required for every visit/encounter
documentation should include indication of no shows and cancellations
all documentation must comply with the applicable jurisdictional/regulatory requirements
all handwritten entries shall be made in ink and will include original signatures, date and
time. electronic entries are made with appropriate security and confidentiality provisions
charting errors should be corrected by drawing a single line through the error and
initialing and dating the chart or through the appropriate mechanism for electronic
documentation that clearly indicates that a change was made without deletion of the
original record

SOAP Note Format - answer the term "SOAP notes" refers to a particular format of
recording information regarding treatment procedures. documentation of treatment is an
extremely important part of the treatment process. in virtually all employment settings,
some form of documentationis required and SOAP notes are the most popular format in
medical settings

S - answer subjective: this should reflect the patient and/or caregiver self report of
status and response to previous treatment(s)

O - answer objective: this should reflect the physical therapist's objective findings
made through observation of the patient, as well as tests and measurements. the
treatment provided to the patient and the response to treatment on that specific date
may be included in this category, but not in lieu of objective data

A - answer assessment: this should reflect the physical therapist's clinical problem
solving, including his or her professional assessment of the patient's status, response to
therapy, functional limitations, and possible precautions

P - answer Plan: the physical therapist should provide information related to the plan
for future services including patient/caregiver education and any possible changes in
the treatment program

OSH - answer outside hospital

DME - answer durable medical equipment

PTA - answer prior to admission

chart review - answer PMH, HPI, medications, PLOF, Precautions, lab results

PMH - answer past medical history

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