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201 exam 1
Documentation Standards
| Question | Answer |
|---|---|
| What is the over riding legal/ethical principals involved in documentation? | If you do not chart it, it did not happen! |
| Why do we document? | So other therapists can recreate treatment Meet JCAHO/CARF requirements Payment from 3rd party payor/insurance |
| principles of documentation | fact-based charting measurable goals time dated goals functional goals comparative analysis |
| fact based charting | Subjective information should contain only information pertinent to the patient’s care |
| timed-dated goals | need to anticipate target dates |
| functional goals | LT goals needs to have a measurable part and the reason why ex: 160 deg of shoulder flexion to reach into cabinet |
| comparative analysis | progress notes that contain comparative statements |
| consistent documentation | Report the same targeted behaviors from week to week |
| If a treatment goal has been achieved and a new goal is added, an updated ____ ___ and a ___ ____may be necessary especially for a change in weight bearing status ie:(Going from a walker to a cane) | treatment plan, physician’s order |
| importance of documentation | provides evidence of basis on which care decisions are made only legal record Provide the foundation for eval of the care provided Primary source of comm among the health care team. (Especially covering therapist justify reimbursement from payors |
| Evaluation | Gather baseline information establish a problem list develop goals based on problem list justification of why we are treating |
| what 3 questions should the eval answer? | why now = medical necessity why me = skilled intervention so what = measurable outcomes |
| what must POC include in outpatient | assessment goals tx codes |
| most common form of daily note | SOAP (can also do SOAPE - extra) |
| subjective | what the pt tells you |
| objective | Reflect treatment rendered related to impairments identified at the time of evaluation Must work toward the goals/within POC observations |
| assessment | Specific Progress Set new STG/ Modify goal |
| plan | for next tx and discharge |
| weekly summaries | weekly conferences Some have team documentation, others by discipline |
| purpose of weekly summaries | Identify and justify skilled intervention performed by Physical Therapy to this point Justification for the need for further therapy Compare previous to current progress – Include past social history |
| weekly summaries are ____ oriented, based on ___ | functionally, outcomes |
| purpose of monthly updates | Which level of care requires what? Justify continuance of skilled care Document functional gains, if none Why? Functionally based measurable LT Goals Recertify from MD |
| LTG criteria (PT writes) | Need to be able to write short term goals from them Functional action Measurable Have a time frame Usually greater than 2 weeks from eval Needs to be realistic and meaningful for the pt. |
| example of LTG | Mr. Jones will walk Independently for distances up to 1000 ft. outdoors w/o assistive devices within 1 month. |
| STG criteria | PT writes or PTA? Functional Measurable Timeline Let PT know when met Write new goals |
| STG example | Mr. Jones will walk 200 ft. on level surfaces indoors with quad cane and requiring CGA within 1 week. |
| paper documentation tips | Legibility is Key! Use permanent black ink NEVER use whiteout (draw line through incorrect entry, initial) |
| documentation tips | Time / Date/ Sign each entry – include your title Correct an error by drawing a single line through entry; initial it with date and time Limit use of abbreviations |
| Describe interventions and ____ to care and/or teaching | response |
| Demonstrate____ &_____ | skilled care, medical necessity |
| Be objective/Report ____ regularly | functional progress |
| When training multiple caregivers, use ____ identifiers (initials to denote individual competence | identifiers (initials) |
| things to avoid when documenting | Relying on memory Cross out beyond recognition Leaving blank space between entry and signature Leaving gaps in documentation Unfamiliar abbreviations |
| how can you create a picture with your documentation | Focus on PT problems Keep interventions related to eval findings Use descriptive words (safety, mobility, activity) Measure functional change toward goals If factors have limited gains; state them, consider plan change |
| what to document with telephone communication | Date, Name of person calling Name of patient Dr.’s /clinic name Insurance Details of referral Ask for a written prescription if applicable (TENS/Splint) Document in chart that PT or Nurse notified |
| what can the PTA take calls on? | can take calls regarding cancellations or change in a patients condition If patient is much worse, may need to refer patient to their physician |
| what to document after a call as the PTA | Date/time/name of person calling Summary of conversation – including what you said Sign and let PT know ? emotional state of patient – (I would be leery of this) |
| rule of thumb for information request on a pt | DO NOT give ANY information about the patient over the phone unless you are absolutely sure you are talking to whom you think you are talking to. “I’m sorry but I am unable to provide that information” |
| means of sending pt information | fax email - not ideal because not secure/ encrypted phone |
| who might ask for pt information? | Attorneys, Insurance Reps Parent of Child Employer Relatives, Friends Researchers |
| what information about the pt is confidential | Information regarding the patient’s condition and treatment |
| who has direct access to information | Those providing direct care – have access to information |
| who needs a release of information form signed to access pt information | Those not having direct care, needs to be signed by pt, family, POA |
| handling of paper charts | Secure – Locked File Not left out on desk Do not take home |
| handling of EMR | Lock screen Minimal use by support staff Encryption |
| who is the legal owner of the medical record | health care facility |
| can the pt access their own medical record? | yes with signed request form |
| summary of care | record of visit available to pt, MIPS requirement |
| how is consent of tx obtained? | Verbal Written – Informed consent form – ensures no coercion occurred |
| informed consent form should contain | Patient is informed of treatment/plan, risks and alternatives Name of therapist/clinic responsible for treatment |
| what do you do if a pt disagrees/ refuses? | active listening no adequate reason for refusal pt does have the right to refuse therapy document |
| what should you tell the pt if they have no adequate reason for refusal? | Your Dr. ordered therapy and he/she feels you would benefit from therapy. I will let your PT and Dr. know that you declined therapy today” Make sure Patient understands treatment purpose and consequences for no treatment |
| components of documenting refusal | Statement of refusal Reason for refusal PTA’s response “Consequence of refusal discussed etc.” PT/Dr. notified |
| two types of incident reports | Patients and visitors Personal therapist injury |
| when do you need to fill out incident report | Usually involves an accident May involve incorrect treatment or procedure As soon as Possible – some require within 24 hours |
| purpose of incident report | It protects you, patient/visitor and the facility Preserves information for litigation Risk management Alerts facilities lawyer and insurance company |
| what to do if an incident occurs to a pt/visitor | Notify PT, give form to PT Get an okay from Administration before filling out an incident report Obtain form and policy May want to write your explanation on a separate piece of paper, then rewrite it on the form legibly with professional language |
| what does incident report contain | Name and address of patient/visitor Objective/facts only – no assessment List sequence of events Identify condition of patient after the incident Include names and information of any witnesses |
| what should you not do with an incident report | Do not write anything in the report that blames – just the facts Do not talk about the incident to anyone not involved with patient |
| An incident report is not part of the____, it is not placed in the patients file | medical record |
| PTA must document the incident in the ____ (Not that an incident report was written) | chart |
| What to be aware of with incident reports regarding injuries to yourself | If you are injured on the job you may only have 24 hours to fill our an incident report Protect yourself – fill one out even in doubt If you do not fill one out then L & I will not pay Usually a Dr.’s follow-up will need to take place |
| do's and don'ts of incidence reporting slide 28 |
Created by:
bdavis53102
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