Physical Therapist Assistant Program

Assignment 1 PHT 1131 Documentation – Erickson & Mcknight

Chapter 3 & 4 Due 9/9/2020 (25pts)

INSTRUCTIONS:

READ CHAPTERS!!

· Must be typed using Microsoft Word and in your OWN words.

· Be careful of spelling, grammar and sentence structure. MUST proofread.

· DO NOT rewrite questions, keep answers SHORT, clear and concise.

COMPLETE:

· Complete Chapter 3 Q1-Q6 & Q8-Q10 Pg. 25 (9 Pts)

· Complete Chapter 4 Q1-Q8 Pg. 38 (16pts)

· Define ALL key terms (10pts)

· Must be Handwritten in your OWN words

CHAPTER 3

1. List reasons for documenting.

* The most important reason for documentation is to maintain a record of the patient. Reflect the progress of the patients. Provide a legal record of care also is a source of information for clinical research. Medical record is legal documents, and any entry of you make into the medical record become legal.

2. Review the Standards of Ethical Conduct for the Physical Therapist Assistant (http://www.apta.org/uploaded-Files/APTAorg/About_Us/Policies/Ethics/StandardsEthicalConductPTA.pdf) and identify your professional obligation(s) that pertain to documentation.

* The Physical Therapist Assistant must document appropriate individual’s information to ensure that is going to receive the most efficient treatment. Documentation is one of the most important aspects of this environment because ensures that physical therapist services accurately reflect the nature and scope of the services provided. In the documentation, PTA’s must abide by professional standards, ethical codes, accreditation standards, and legal requirements in creating a permanent record of patient/client data. The medical record is the most important documentation defending against or preventing legal actions.

3. What are some examples of subjective and objective data that can be gathered by a physical therapist assistant?

*Physical therapy collects the patient history-taking portion of the initial examination, provides the physical therapist with subjective information, history or similar problem are examples of subjective information. Objective data provide additional information to help identify and measure the extent of the patient’s impairments, activity limitations, and participation restrictions.

4. How can a clinician integrate the clinical decision-making process in his or her documentation?

* By collecting subjective and objective data, asking the patient about his/her response to previous treatments and which one has improved his/her motor functions. Collecting objective data trough tests and measurements, taking daily notes.

5. Provide some examples of how a physical therapist assistant can assist in showing clinical decision making in the medical record.

* Document the patient’s overall response to treatment. Documentation will also serve as a record of the care provided. When assisting the patient taking note to see how the rehabilitation plan improves their status.

6. What are the criteria for determining whether a treatment or intervention is reasonable and necessary?

* Documentation can support the need for subsequent or continued interventions. documentation makes it easier for the clinician to identify progress or lack this also allows the physical therapist to easily update goals and interventions as need.

8. What is the difference between skilled care and maintenance therapy? Provide an example of each.

* Unskilled services are often known as maintenance therapy can be provided by a non-licensed individual. A family member can provide can perform the rehabilitation exercises.

Skilled care is performed under the supervision of professionals. PTA when performing the therapy.

9. What is the role of the physical therapist assistant in determining medical necessity?

* Physical therapist assistants record the patient’s responses to treatment, and report the outcome of each treatment to the physical therapist.

10. How does the patient’s rehabilitation potential influence his or her need for medically necessary skilled care?

* It has a direct influence on the recovery of the patient, since rehabilitation is one of the components of specialized medical care, and it is intertwined with care and therapeutic activities. In addition to facilitating the social integration of the disabled patient.

Maintenance therapy: is simply to help the patient maintain the current level of function.

Medicaid: is a public health insurance program in the United States that provides health care coverage to low-income families or individuals

Medicare: is the federal government program that provides health care coverage if you are 65+.

Objective data: obtained through observation, physical examination, and laboratory and diagnostic testing

Reasonable and necessary criteria: is a term used to determine what kind of funded supports you might need. Simply put -reasonable is something that is considered fair, and necessary is something that you need

Reimbursement: is money paid to an employee or customer, or another party, as repayment for a business expense, insurance, taxes, or other costs

Skilled care (services) Subjective data are information from the client’s point of view (“symptoms”), including feelings, perceptions, and concerns obtained through interviews

CHAPTER 4

1. List 4 documentation formats used in physical therapy.

* Narrative, Problem-oriented medical record (POMR), SOAP note, functional outcomes report (FOR)

2. Describe the similarities and differences between narrative notes, POMRs, SOAP notes, and FOR.

* Narrative notes: Information written in paragraph form, Describe a succession of events, describing interactions any situation requiring detailed explanation.

Problem-Oriented Medical Record (POMR): Organized according to pt problems. Each situation should answer 5 questions: Subjective data, Objective data, Impression, Treatment, Plan-treatment plan.

SOAP: (subjective, objective, assessment, plan)

Functional Outcomes Reporting (FOR): demonstrates the effect of impairment on functional limitations.

3. Describe the advantages and disadvantages of narrative notes, POMRs, SOAP notes, and FOR.

POMR Advantages: Provides a specific plan, provides organization and structure.

POMR Disadvantages: Very time taking for pt’s with multiple problems

SOAP Advantages : Provides structure and logical problem solving

SOAP Disadvatages: Recorded in terms of impairments

FOR Advantages: Improves read ability for non-health care provider.

4. What type of information is found in the S, O, A, and P portions of a SOAP note?

*SOAP (subjective, objective, assessment, plan) note is a method of documentation used specifically by healthcare providers.

S: Subjective: Describe your impressions of the client and support those impressions with observed facts

O: Objective: is where you document measurable outcomes about your patient’s performance
A: Assessment: Describe your analysis about patient’s progress.
P: Plan: in patient’s treatment all activities, objectives, or reinforcements that u are changing.
5. When using SOAP and POMR formats, where should you place information provided by the patient’s family?

* We should place that information in SOAP notes in (Subjective information) and in POMR we should place that information in

6. Describe how the FOR and SOAP format can be used together.

*Provide information about the patient’s functional status, provide a broader picture of an individual’s health, describe how betterment that will lead to better activity.

7. What are the positive and negative aspects of using forms and templates?

Positive: Minimize writing, save time, improve accuracy and consistency

Negative: are often geared toward the patient population treated most at the facility and might be difficult to use these forms when documenting on patients with less common diagnoses

8. Why is it important to learn the different documentation formats?

Is important to learn different documentation formats because is where patient information is placed to check his/her progress during the rehabilitation plan. Medical information is stored because based-documentation can be use for future interventions.

Assessment: is the evaluation of the health status by performing a physical exam after taking a health history

Functional outcome report: define results of care focused on the patient’s physical ability.

Individualized education plan: IEP–program of goals and methods for addressing the needs of students with a disability

Individualized family service plan: IFSP–

Individuals with disabilities in education act: is a plan to obtain special education services for young children

Narrative: something that is narrated

Objective: is where you document measurable outcomes about your patient’s performance

Plan: in patient’s treatment all activities, objectives, or reinforcements that u are changing.

Problem-oriented medical record: is a comprehensive approach to recording and accessing patient medical data

SOAP note: is a way for healthcare workers to document in a structured and organized

Subjective: refers to how individuals evaluate their health status