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Summary Slide

n Summary Slide

Summary Slide

n Documentation

Documentation

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DocumentationEvidence of Patient Caren Evidence of patient care

n Proves care was given

n Reason for treatment

n Treatment effectiveness

n Communication:b/n PT/PTA to document progress & Rxb/n PT & other disciplines to coordinate care

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DocumentationAccountability for Caren 3rd party payers review notes to determine if they

will pay based on appropriateness of care andeffectiveness

n focus on FUNCTION

n Care Provider is held accountable for medical caregiven

n if we don’t get reimbursement for PT servicesphysical therapy will cease to exist

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Legal Document

protects you and patient

n can be used in a court of law

n ***it doesn’t matter how effective yourtreatment is – if you didn’t document –it didn’t happen!

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Evolution of PT/PTA Responsibilities

n Physical therapy prescription prior to1960’s

n PT’s were technicians; Dr. gave thepatient a prescription that was very specifici.e. US 3x/week for 2 weeks

n PT’s documented treatment given and ifpatient improved

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Role of PT & PTA’s1960’s

Evaluate and treat, 1960’s:

PT prescriptions often said eval and treat

PT’s began evaluating neuromuscularsystem and determined appropriate Rx

PTA’s began around 1967 became technicians under supervision of PT & shareddocumentation

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Direct Accessn Pt. can come directly to PT

n PT given clinical decision making opportunity

n PT education shifted to scientific knowledge,evaluative skills, creative thinking

n So PT would know when problems were NOTPT problem and to make appropriate referralsto MDs etc.

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Changes in Response toDirect Access

n PTA education gave more theories fortreatments so PTA can make decisions withinparameters of PT POC

n PTA’s role now includes performingassessments and reporting to the PT anychanges, lack of progress or signs &symptoms that would indicate a need for aPT re-evaluation

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Role of Documentation inPatient Care

1. Records the QUALITY of patientcare:

Quality: is defined by the APTA inthe Standards of Practice

Is it appropriate and relevant for thepatient’s problem?

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Documentation/qualityn Documentation is used to determine quality of care by: audits

a. Quality assurance/management- does it meet standards and criteria; Performed by facility on-going and by accrediting bodies every 5-10 years

b. Research: what works best; cost-effective

c. Third-party payers: decide reimbursement based on doc.;must show problems were identified, treatment solvedproblems

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Role/ quality caren Must have communication between the team for

patient’s problems, solutions, plan and to coordinatecare.

n Must have communication between the PT/PTA; it’svital everyone understands the problems, plan andwhat was done, the patient’s response, etc

n Patient’s response to treatment and progress towardgoals

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Role/Communication

n Medical Record for communication b/nmedical team:

n 1. Identification of pt.’s problemsn 2. Solutionsn 3. Plans for pt.’s dischargen 4. Coordination of care

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Role of Documentation inPatient Care

n Legal report of patient care

n Testify in court case

n Basis for reimbursement

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Standards & Criterian 1. Federal Government – medicare

n 2. State Government – medicaid

n 3. Accrediting Agencies –n Hospitals – JCAHOn Rehab Facilities – CARF

n 4. Health-Care Facilityn Quality Assurancen Policies & Procedrues

n JCAHO: Joint Commission AccreditingHealthcare Organizations

n CARF: Commission Accrediting RehabilitationFacilities

n HCFA: Health Care Finance Administrationissued standards for documentation withpatients on Medicare; wanted accountabilityfor how dollars for healthcare were spent

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Documentation Content

Content Categories:n Data relevant to pt.’s conditionn Problem(s) requiring medical txn Tx plan or action to address problemsn Goals or outcomes of tx plann Record of administration of tx plann Tx effectiveness/results of tx plan

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Relevant Datan SUBJECTIVE information told by pt. or family

member to PT/PTA or HCP (Health Care Provider)n Symptomsn Medical historyn Cause(s) of symptomsn Patient’s functional and lifestyle needsn Patient’s goals or expectations from treatment

n OBJECTIVE: measurements, tests, observations,reproducible, repeat testing during course oftreatment

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Problem(s)

n Medical Diagnosis:n Determined by physician’s eval and

diagnostic tests

n Physical therapy problemn not medical diagnosisn neuromusculoskeletal dysfunctionn functional limitation

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Problems

n Medical Diagnosis:n Systemic diseasen Pathologyn Ex:

n Fractured femurn Rheumatoid Arthritisn CVAn Parkinsonsn Multiple Sclerosis

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Problems

n PT Diagnosis – NOT a medical diagnosisn Biomechanical or neuromuscular problemn Impairments & Functional Limitationsn Ex:

n Ataxian ROM deficits unable to dress independentlyn Unsafe gait

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Terminologyn * APTA Guide to PT Practice: begin with

pathology which leads to impairments whichmay lead to functional limitations: “restrictionof ability to perform a physical action, activity,or task in an efficient, typically expected orcompetent manner”

n Disability: “inability to engage in age-specific,gender-specific, or sex-specific roles in aparticular social context and physicalenvironment”

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Treatment Plan or Action

n Determined by problemsn Frequencyn Durationn Informed consent: obtained by PT;

provide pt. with info about Rxn Established by PTn Strategies to minimize problem and

increase function

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Goals & Outcomes

n Established by PT (should include pt.s goals)

n Gives PTA direction for –(planning Rx sessions,progressing Rx)

n Recommending Rx termination

n DIRECTLY related to problems

n Functional Outcome Expected

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Record of Administration ofthe Rx Plan

n Flow chartsn Progress notesn Recording of Rx provided for each

problemn Patient’s reaction to treatmentn Progress towards goals or outcomesn PROVIDES PROOF of what was done

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Treatment Effectivenessn Patient’s response to Rx (progress toward

goals, goals met)n MOST IMPORTANT PART; is interpretation of

pts response to Rxn Quality of medical care providedn Research to determine the effectiveness of

treatment proceduresn Third party payers use to determine

reimbursement

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Exam/Eval by PT5 Elements of PT Management

n Examinationn Evaluationn Diagnosisn Prognosisn Intervention

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Terminologyn Examination: process of gathering subj & obj.

datan Evaluation: “clinical judgment” by PT based

on the examination; decide PT dx, prognosis,interventions

n Prognosis: judgment regarding patient’sability to improve, level of improvement andtime required

n Interventions: skilled techniques andactivities in POC

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Physical Therapist DocumentationResponsibilities & Role

n Initial Evaluation:n Discharge Evaluationn Progress/treatment Notesn Interim Re-Evaluationn Change in Treatment Plan

n *See Appendix F for APTA Guidelines for PTDocumentation

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PT Initial Evaluation

n Hx & risk factor Identificationn May find in chartn Agen Medical Dxn Namen Sexn DOBn Complicationsn Precautions

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PT Initial Evaluation cont’dn Subjective Data:

n Pt. or family member “tells” PTn Onset of injury/disease/painn Chief Complaintn Location of Complaintsn Functional Limitationn Home Situationn Lifestylen Goalsn Work Requirements

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PT Initial Evaluation cont’d

n Objective Datan Results of assessments

n MMT, ROM, balance, gait, transfers, endurance,skin condition, functional status, ADL’s, abilitywork, school, home, & mental status, cognition,orientation, communication, judgment, abilityto follow directions

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PT Initial Eval cont’d

n Evaluation

n PT’s “interpretation of the results of thetesting and observations”

n Find in Assessment component of SOAPnote

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PTInitial Evaluation cont’d

n PT Diagnosis

n Identify impairments and functionallimitations

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PT Initial Eval cont’d

n Goalsn Goals & expected outcomes

n MUST be MEASURABLE and FUNCTIONAL

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PT Initial Eval cont’d

n POC: plan of caren Interventions and treatment to accomplish

goalsn Frequencyn Durationn Prognosis (Rehab potential)

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PT Initial Evaluation cont’d

n Authentication:

n PT signature

n PT title

n Professional License Number

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PTA Documentation Role &Responsibilities

n Progress/treatment/interim noten May assist PT in gathering data for evaluationn May NOT interpret data, set goals, design

treatment plan

n PTA is responsible for following treatmentplan to meet goals outlined in PT Eval.

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Organization & Presentation of Content

n Formatn Used to organize pt info in chartn Varies from facility to facilityn Often depends on setting

n Acute Hospitaln Out-patient PT Clinicn Rehab Facility

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Organization of the Medical Record

n Types of Organizationn SOMR: Source Oriented Medical Record

n POMR: Problem oriented Medical Record

n Combination of SOMR & POMR

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SOMR

n Organized by medical servicesn Physiciann Nursingn Physical therapyn Occupational therapyn Respiratory therapy

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SOMR

n Each discipline documents in theirsection their contentn Datan Problemsn Treatment plann Goalsn Progress notesn Treatment Effectiveness

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SOMR

n Disadvantages of SOMRn Other disciplines may be unaware of pt

problemn Time to locate & read other disciplinesn Difficult to audit for reimbursement &

quality control

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POMRProblem Oriented Med. Record

n Organized by identification & Rx of pt.’sproblems

n Sequencen Data Basen Problem Listn Treatment Plansn Progress Notesn Discharge Notes

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POMR

n Each discipline places the info in thesection

n Advantagesn Improved communication b/n disciplinesn Problems all in one placen Treatments all in one placen Easier for auditors

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Organization of theDocumentation Content

n Ways to Organize Notesn SOAP: Subjective, Objective, Assessment,

Plann PSP: Problem, Status, Plann PSPG: Problem, Status, Plan, Goalsn DEP: Data, Evaluation, Performance Goalsn FOR: Functional Outcome Report

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SOAP Note

n Most common method to organize info

n Logical Sequence

n Organized for quick & easy reading &locating info

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SOAP Note cont’dS=Subjective

n Info told by pt., caregiver, familymember

n Symptomsn Historyn Previous Medical Historyn Response to treatmentn Activity level

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SOAP Note cont’dO=Objective

n Data that can be reproduced orconfirmed by another professional withsame training

n Gathered by “measurable &reproducible tests and observations”

n “signs” of pt.s disease or dysfunction

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SOAP Note cont’dA=Assessment

n PT or PTA summarizes S & O info toanswer “What does it mean?”

n PT interprets & makes clinical judgmentn PT sets functional outcomes & goals

based on info in S & On Report progress toward goalsn “SO WHAT”

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SOAP Note cont’dP=Plan

n What will happen next?

n PT treatment plan

n PTA in progress note what you will doin next treatment or before nexttreatment

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SOAP Note Examplen Dx:Fractured L anklen Pr: NWB LLE requires A.D. for amb.n S: Pt reports 1 flight of stairs in home, curbs & ramps

at work. Pt reports she has never used an A.D.before

n O: Instructed pt. in NWB LLE 3.0 gait pattern withcrutches. Pt. ambulated 50 feet with min asst forbalance and verbal cues 50% of times for correct gaitpattern on level surfaces.

n A: Pt. needs to continue gt training to reach goal of Ion level surfaces, ramps, and stairs.

n P: Cont gt training BID for 3 more treatments

PSPProblem, Status, Plan

n P= problem/diagnosis

n S=: subjective & Objective data

n P= modified treatment plan based onclinical findings

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PSPGProblem, Status, Plan, Goals

n Same as PSP with addition of Gn G= functional goals

PSPProblem, Status, Plan

PSPG

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FORFunctional Outcome Report

n Structured format for reporting “functionalassessment & outcomes

n FOR Sequencen Reason for referraln Functional limitationsn Physical therapy assessmentn Therapy problemsn Functional outcome goalsn Treatment plan & rationale

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FOR cont’dn Reason for referral

n Diagnosis, PMH, subjective data

n Functional Limitations & PT Assessmentn Objective data

n Physical problemsn Problems identified by data

n Functional Goals

n Treatment Plann How it relates to goals & how goals will be accomplished

FORFunctional Outcome Report

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ContentOrganization/Sequencing

n 1. Gather Datan 2. Interpret Data to identify PT Dxn 3. Develop goals & outcomesn 4. Treatment plan/interventions to meet

goals & functional outcoms

Guidelines for organizing noten PT diagnosisn Subjective datan Objective datan Meaning of data “so what”; relate to treatment

effectiveness and progress toward goals & functionaloutcomes

n Plan

n *can follow these guidelines for organizing note evenif narrative paragraph form rather than SOAP, PSP,PSPG, FOR

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Formats

n Computerizedn Flow Chartsn Checklistsn Lettern IEPn Cardexn Standardized Medicare Forms

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Formats

n Computerizedn If pre-programmed phrases, must make

sure individualize for specific pt.sn Content must show skilled need

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Flow Charts & Checklist

n Fill in the blank formsn Advantage can locate quicklyn Can combine narrative with flow chartn Disadvantage: often no note is

combined with flow chart so no skilledneed is demonstrated

Flow Chart

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Letter Format

n Often used in private practicen Sent to referring physician

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Cardexn PT Departmentn Pt.’s goals & treatment interventionsn Available for quick accessn Written in pencil for easy updatingn Must be updatedn NOT part of medical recordn Disadvantage: still need to review chart prior

to pt. treatment to review other disciplinesand pt. info

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Standardized Medicare Forms

n HCFA: Health Care Financing Administrationn HCFA: specifies time lines & formatn Not completed by PTA because evaluation or

re-evaluation formn Form also serves as discharge evaln PTA can provide info to PT but not complete

formn PT completes these forms

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n Pg. 36 & 37 & 38 in doc bookn Examples of checklist & progress note

forms

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IEPIndividual Education Program

n Treatment provided in public schoolsn Team records goalsn Team has periodic meetings to review goalsn Team meets with parents every 7 monthsn PT completes IEPn PTA can write progress notesn Pg. 39