Introduction to Physical Therapy Documentation Questions and Answers

Introduction to Physical Therapy Documentation Questions and Answers Why do we document? 1. serves as a record of patient/client care including a report of the patients/client's status, physical therapy management, and outcome of physical therapy intervention 2. is a tool for the planning and provision of services, and is a communication vehicle among providers 3. tells others about our abilities, our unique body of knowledge, and the services we provide as PTs and PTAs 4. may be used to demonstrate compliance with federal, state, payer, and local regulations 5. provides an historical account of patient/client encounters that can be used as evidence in potential legal situations 6. May be used to demonstrate appropriate service utilization and reimbursement for many third-party payers 7. may be used for policy or research purposeds including outcome analysis top 10 payer complaints about documentation (reasons for denials) poor legibility incomplete documentation no documentation for date of service abbreviations - too many, cannot understand documentation does not support the billing (coding) does not demonstrate skilled care does not support medical necessity does not demonstrate progress repetitious daily notes showing no change in patient status interventions with no clarification of time, frequency, duration things to avoid when documenting "Patient/client tolerated treatment well" "continue per plan" "as above" "unknown/confusing abbreviation" - use abbreviations sparingly VC vital capacity MMT manual muscle testing WBAT weight bearing as tolerated PLOF prior level of function WNL within normal limits WFL within functional limits general guidelines documentation is required for every visit/encounter documentation should include indication of no shows and cancellations all documentation must comply with the applicable jurisdictional/regulatory requirements all handwritten entries shall be made in ink and will include original signatures, date and time. electronic entries are made with appropriate security and confidentiality provisions charting errors should be corrected by drawing a single line through the error and initialing and dating the chart or through the appropriate mechanism for electronic documentation that clearly indicates that a change was made without deletion of the original record SOAP Note Format the term "SOAP notes" refers to a particular format of recording information regarding treatment procedures. documentation of treatment is an extremely important part of the treatment process. in virtually all employment settings, some form of documentationis required and SOAP notes are the most popular format in medical settings S subjective: this should reflect the patient and/or caregiver self report of status and response to previous treatment(s) O objective: this should reflect the physical therapist's objective findings made through observation of the patient, as well as tests and measurements. the treatment provided to the patient and the response to treatment on that specific date may be included in this category, but not in lieu of objective data A assessment: this should reflect the physical therapist's clinical problem solving, including his or her professional assessment of the patient's status, response to therapy, functional limitations, and possible precautions P Plan: the physical therapist should provide information related to the plan for future services including patient/caregiver education and any possible changes in the treatment program OSH outside hospital DME durable medical equipment PTA prior to admission chart review PMH, HPI, medications, PLOF, Precautions, lab results PMH past medical history HPI history of the present illness patient management examination - evaluation - diagnosis - prognosis - intervention - outcomes initial examination/evaluation examination (history, systems review, and test and measures) documentation of history may include general demographics social history employment/work (job/school/play) growth and development living environment general health status (self-report, family report, caregiver report) social/health habits (past and central) family history medical/surgical history current condition(s)/chieft complaint(s) functional status and activity level medications other clinical test systems review cardiovascular/pulmonary - blood pressure - edema - heart rate - respiratory rate integumentary - pliability (texture) - presence of scar formation - skin color - skin integrity musculoskeletal - gross range of motion - gross strength - gross symmetry - height - weight neuromuscular - gross coordinated movement (balance, locomotion, transfers, and transitions) - motor function (motor control, motor learning)