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255 exam 1
Quality Assurance Documentation
| Question | Answer |
|---|---|
| defensible documentation | record of patient/client care including a report of the patients/client’s status physical therapy management, and outcome of physical therapy intervention. Is a tool for the planning and provision of services, communication vehicle among providers. |
| what does defensible documentation tell others about? | our abilities, our unique body of knowledge, and the services we provide as PTs and PTAs. |
| what may defensible documentation be used for? | to demonstrate compliance with federal, state, payer, and local regulations. |
| what does defensible documentation provide? | appropriate service utilization and reimbursement for many third-party payers. |
| defensible documentation may be used for ____ or____ purposes including outcomes analysis. | policy or research |
| when is documentation required? | every visit |
| what should documentation include? | indication of a patient’s/client’s cancellations of appointments and/or refusal of treatment. |
| All documentation must comply with the applicable ____ requirements. | jurisdictional/regulatory |
| how should handwritten entries be made? | ink, dated, and properly authenticated. Legibility is critical in clinical documentation. If an entry cannot be read, it cannot be understood. |
| electronic entries should be made with appropriate ____ and ____ provisions | security, confidentiality |
| Documentation must include adequate _____of the patient/client, the physical therapist, and/or physical therapist assistant: | identification |
| what may defensible documentation be used for? | - historical account of pt/client encounters that can be used as evidence in legal situations - demonstrate appropriate service utilization and reimbursement - policy or research including outcomes analysis |
| tips for defensible documentation | slide 7 |
| Document _____ /____ process. Indicate why you chose the interventions/why they are necessary. | clinical decision making/problem-solving |
| Document interventions connected to the ____ and _____ | impairment and functional limitation. |
| Document interventions connected to ____ stated in plan of care. | goals |
| what needs to be identified in all documentation? | who is providing the care (PT/PTA) |
| Document complications of ____, ____ | comorbidities, safety issues, etc. |
| Services are consistent with ____ and _____of illness, injury, medical needs. | nature and severity |
| Services are ____, ____ and ____ according to accepted medical practice. | specific, safe, and effective |
| There should be a reasonable expectation that ____ and ____ improvement in functional ability will occur. | observable and measurable |
| Services do not just promote the ____ of the patient/client. | general welfare |
| how to document progress | Update goals regularly. Highlight progress toward goals. Show comparisons from previous date to current date. Show a focus on function. Re-evaluate when indicated. |
| Clearly indicate if this is a progress report by demonstrating _____ | patient/client improvement. |
| when to notify supervising PT | Changes in status Goals being met? Interventions outside POC Any risks or liabilities Payor requirements met with PTA? Reassessment necessary |
| quality assurance (QA) | Review of existing records to monitor: QA, Research and Education, Reimbursement. |
| what does QA determine | if services provided were legal and appropriate. Identifies issues for improvement or correction. |
| who can be a quality assurance reviewer | PTA's/ PT, etc |
Created by:
bdavis53102
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