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Reasons for document

Documentation

QuestionAnswer
Regulation of Documentation-6 Federal Government State Government Accreditation Bodies Professional organizations Third Party payers Facilities
Narrative format Written in paragraph, like a story
Narrative Disadvantages-4 Lack of structure variety hard to locate necessary information difficult to follow
Problem-Oriented Medical Record (PROM) Oriented around patients problems
PROM advantages Organized comprehensive specific plan
PROM disadvantages Don't see the "whole patient" just look at problems time consuming
What does SOAP mean Subjective, Objective, Assessment, Plan
Subjective (S) Anything the patient or caregiver says chief complaint "feelings"
Objective (O) results of tests & measures pt. functional status PT interventions for that day Impairments, activity limitations, and participation restriction obsercation/quality measure
Assessment (A) progress
Plan (P) what to do next time
SOAP advantages widely used structure and flow
SOAP disadvantages often centered around pt. impairments rather than improving function
Functional TASK day to day multiple impairments like activity limitation
5 CPT codes Therapeutic Act therapeutic Exercise Gait training Manual therapy Neuromuscular re-education
Created by: ZanderLuna
 

 



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