Identify the principles of documentation according to the text and slides. correct answers Accuracy: true; objective; correct spelling and grammar.
Brevity: concise and to the point; give enough information so as to leave no doubt; abbreviations may help with brevity; use short concise sentences.
...
identify the principles of documentation according
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PTHA 1409 Exam 2 || A+ Graded Already.
Identify the principles of documentation according to the text and slides. correct answers
Accuracy: true; objective; correct spelling and grammar.
Brevity: concise and to the point; give enough information so as to leave no doubt; abbreviations
may help with brevity; use short concise sentences.
Clarity: meaning is immediately clear to the reader; do not shift tenses; handwriting is legible.
Identify the content of the problem-oriented medical record. correct answers Database: current
and past information about the patient
Problem list: problems to be treated by various practitioners.
Identification of a specific treatment plan by each provider on the case.
Assessment of effectiveness of the treatment plan across time.
Explain the purposes of the four sections of a physical therapy SOAP note. correct answers S -
SUBJECTIVE: information provided by the patient, family or caregiver to you; can be indirect
comments during treatment; focus on statement related to prior to function, current level of
function, reported barriers to achieve function and compliance with treatment ("pt stated"
"spouse stated" "pt denies"); direct quotes;
O - OBJECTIVE: what is done during treatment including interventions and data collection
related to the interventions; measureable; any activity performed by pt during treatment;
charts/tables, flowsheets, photos/video
A - ASSESSMENT: assessment of patient during and after treatment; why does pt need to
continue PT, why should an insurance company pay you to do it, how did the pt perform during
tx, how does their performance affect their functional status, why is your opinion regarding pt
progress?
GOALS: written by PT; statement of anticipated or intended outcomes; LTG/STG;
P - PLAN: what treatment is planned and its progression; What needs to be done next tx session,
do any test need to be done again ot done for first time, how do you plan to progress tx, is there
anything that needs to be discussed with the PT, does the pt require a re-evaluation?
What are the differences between the initial note, progress/daily note, re-evaluation note, and the
discharge note as they pertain to physical therapy? correct answers Initial note:
done by primary care physician, specialist nurse, PT, OT, speech therapist.
Examination, Evaluation, Diagnosis, Prognosis, Plan of care (POC)
Progress/Daily note:
Written periodically
Includes: daily visits, interventions, and reassessments. Frequency determined by facility (may
be daily, weekly, biweekly, or monthly)
3rd party payers require progress notes after every treatment
Re-evaluation note: Patients treatments, progress related to goals and updated POC and goals if
needed
Discharge note:
Written when therapy is discontinued; after a final examination and evaluation are performed
The DC note will give the results of the final examination and evaluation, the goals achieved (or
not achieved and why)
, A summary of interventions received. The DC note will give recommendations by provider or a
discharge plan.
Identify the seven purposes for documentation. correct answers 1)To keep record of patient care
2)To communicate between health care professionals
3)Provides information or justification to third party payers; used to make decisions regarding
reimbursement
4)Assists in decision-making; PT, PTA, and primary physician communicate regarding plan of
care and discharge
5)The format provides a method to organize patient information to assist the physical therapist in
clinical decision-making
6)Provides data for quality assurance and improvement of patient care
7)Provides data for research
Demonstrate the ability to classify statements into the correct section of a SOAP note. correct
answers ...
Compare and contrast long-term and short-term goals. correct answers Long term goals are
written for extended time frames, i.e. months. Helps to plan the treatment and guide to the POC
Short term goals are written in shorter time frames, treatment sessions of 1 to 2 weeks. Direct
treatment to specific needs and problems.
Explain the purposes for writing goals in physical therapy. correct answers The purposes for
writing goals are:
Prioritize the treatment
Measure the effectiveness of treatment
Used to monitor cost-effectiveness
Communication with other healthcare providers about the course of care
Construct a SOAP note following a simulated treatment. correct answers S: Patient reports pain
in R hip as a 6/10 during supported standing, and 4/10 with bed activities. She states
She does not want to go home "until I can walk", and denies fear of falling.
O: ROM: BUE WNL, BLE WNL except R hip flex: 90o. Strength: All major muscle groups 4/5;
R hip not
tested. Bed Mobility: Requires min. assist x 1 to come from supine to sitting. Transfers: pivot
transfer with
mod assist x 1. TherEx: Patient performed heel slides, HS and quad sets 2 sets x 10; sat at B/S x
5 min.; pivot
transfer bed↔w/c x 2.
A: Pain is limiting participation at this time, but patient can perform exercises given extra time.
She would
benefit from skilled PT intervention in order to return to PLOF of I bed mobility and transfers so
that she can
return home.
LTG: Patient will perform I gait c̅SW on all surfaces in 3 weeks in order to return home.
STG: Patient will perform I bed mobility in one week so patient can function safely at home.
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