Administration, Health care roles, Documentation, Legal Issues
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| The primary reason for keeping records... | The improvement of patient care
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| Reasons for keeping records... | Improvement of pt care, requirements of 3rd party payers, research, medicolegal, communication among clinicians, educational
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| What decreases your chances of being sued for malpractice? | A good rapport with patients & families
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| What must be obtained before providing any person other than pt with medical information? | A written medical release
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| When does a pt's parents have access to pt's medical information? | Pt is younger than 18 years old
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| Give an example of person-first terminology. | "A male with a spinal cord lesion at C5 resulting in quadriplegia"
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| What does SOAP stand for? | S-Subjective
O-Objective
A- Assessment
P-Plan
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| Who is responsible for writing the discharge plan? | The Physical Therapist
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| If a pt has met all goals or has reached maximum benefit from PT treatment, what is the therapist's next step? | Discharge pt from treatment & write a discharge plan
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| In an inpatient hospital setting, who is responsible for discharging the pt? | The Physician
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| Define Quality Assurance | An evaluation of pt care, assures the accountability of those providing the care
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| Define Peer Review | The evaluation of a practitioner's care by her/his colleagues
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| Define Utilization Review | A written program that assures proper use of a facility's funds and personnel related to medical necessity
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| Define Program Evaluation | Based on assessing the management of pt's with specific diagnosis; comparisons between outcomes
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| Define Policy as it relates to Policy & Procedures Manuals | Provides extensive information about what is to be done and who is responsible
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| Define Procedures as it relates to Policy & Procedures Manuals | Provides extensive information that is specific to where, when and HOW an activity is accomplished
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| Define Operating Budget | A financial projection, that lists amounts of funds allotted to cover specific expenses including salaries, benefits, supplies, utilities, linen, housekeeping, maintenance...etc
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| Define Capital Budget | A financial projection, for a specific time period, that lists amounts of funds allotted to cover specific expenses related to purchasing of new buildings or equipment
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| Define Accounts Payable | Amount of money owed by a practice or rehab service for goods or services purchased to help run facility or service
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| Define Accounts Receivable | Amount of money owed by patients or others to the PT practice
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| 4 Main guidelines of Ethical Principles | 1. provide equal tx to all pts without regard to status, insurance coverage, race, sexual preference, etc. 2. Doing no harm 3. Respect pt's autonomy (give pts options regarding tx) 4. Select the best tx for the situation (related to safety)
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| What is JCAHO: Joint Commission on Accreditation of Health Organizations? | Primarily responsible for setting the standards for hospitals & determining if minimal standards are being met
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| What is CARF: Commission on Accreditation of Rehabilitation Facilities? | Sets standards & determines if rehab hospitals, work hardening programs, & other outpt rehab clinics are meeting minimal standards in order to get accredited
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| What is CMS: Center for Medicare & Medicaid Services? | A federal agency that determines what and how much will be reimbursed by Medicare for pt care
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| What is OSHA: Occupational Safety & Health Administration? | A federal agency responsible for determining the safety of work environment
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| Medicares definition of "daily" is... | 7 days of skilled nursing & 5 days of skilled therapy per week
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| Requirements of Medicare and Medicaid for hospice care... | require that 80% be provided at the home
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| Eligibility for Medicare/Medicaid reimbursement for Hospice care includes | Medicare eligibility & certification by physician of terminal illness (< or = to 6 months)
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| Medicare Part A covers... | In-patient hospital care (limits # of hospital days), Skilled nursing facilities for first 100 days, HHA, Hospice care
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| Medicare Part B covers... | Physician visits, Outpt lab tests & x-rays, Outpt physical & occupational therapy, Home health care provided by pT in indep. practice, Durable med equipment, residents of long-term care facilities
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| Medicaid covers... | provides health care services to the poor, elderly, disabled regardless of age who do not receive Medicare
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| HIPAA privacy rule... | Patient confidentiality is maintained in all oral, written, and electronic forms
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| List components of the ICF Model: International Classification of Functioning | Function: Body Functions, Body Structures, Activities, Participation
Disability: Impairments, Activity Limitations, Participation restrictions
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| Documented goals should address... | Who will participate in the activity. A detailed description of activity. The connection of activity to specific function. A specific measure of success. A time measure.
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| Before providing a service or planning a new facility what should be done first? | A Needs Assessment
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| What is a Needs Assessment composed of? | Internal factors: strengths & weaknesses of organization to meet needs of consumer
External factors: true wants & needs of target population
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| The Four Basic Steps of Program Development | 1. Needs Assessment
2. Program Planning
3. Program Implementation
4. Program Evaluation
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| Types of Utilization Review | Prospective Review, Concurrent Review, Retrospective Review, Statistical Utilization Review, Peer Review, Audit/Program evaluation
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| What type of approach to pt care is considered the most effective in today's health care system? | Inter-disciplinary approach
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| What is IDEA: Individuals with Disabilities Education Act? | Ensured children with disabilities receive appropriate, free public education
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| Which category of the ICF does Manual Muscle Testing test for? | Body Structure & Function
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| Which category of the ICF model does the Dynamic Gait Index test for? | Body Structure & Function
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| Which category of the ICF does the Stroke Impact Scale test for? | Participation
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| Which category of the ICF does the SF-36 test for? | Participation
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| Which category of the ICF does the Berg Balance Scale test for? | Body Structure & Function
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