Documentation questions | Nursing homework help
- Reasons for documenting include:
- Legal requirements
- Reimbursement purposes
- Communication with other healthcare professionals
- Quality assurance and improvement
- Research purposes
- Patient education and involvement in their care
- Professional obligations that pertain to documentation include:
- Accurately and objectively documenting patient/client care
- Maintaining confidentiality and privacy of patient/client information
- Avoiding conflicts of interest
- Complying with legal and regulatory requirements
- Seeking appropriate supervision when necessary
- Providing truthful and accurate information to insurance providers
- Examples of subjective data that can be gathered by a physical therapist assistant include the patient’s pain level, their perception of their functional ability, and their description of their medical history. Objective data can include measurements of range of motion, strength, and balance.
- Clinicians can integrate the clinical decision-making process in their documentation by using standardized assessments, creating individualized care plans, and documenting progress towards goals.
- Physical therapist assistants can assist in showing clinical decision-making in the medical record by documenting the rationale for treatment choices, progress towards goals, and modifications to the treatment plan.
- The criteria for determining whether a treatment or intervention is reasonable and necessary include the patient’s diagnosis, the treatment’s potential for functional improvement, the intensity and frequency of the treatment, and the patient’s response to the treatment.
- Skilled care involves services that require the expertise of a licensed healthcare professional, such as physical therapy, while maintenance therapy involves services that are aimed at preventing or slowing further decline in function, such as exercise or monitoring of chronic conditions.
- The role of the physical therapist assistant in determining medical necessity involves gathering and documenting data to support the need for skilled services and communicating with the supervising physical therapist as necessary.
- The patient’s rehabilitation potential can influence their need for medically necessary skilled care because it can help determine the expected outcomes of treatment and the intensity and frequency of services needed to achieve those outcomes.
- The four documentation formats used in physical therapy include narrative notes, problem-oriented medical records (POMRs), SOAP notes, and functional outcome reports (FORs).
- Narrative notes, POMRs, SOAP notes, and FORs are all documentation formats used in physical therapy to document patient care. Narrative notes are a free-form type of documentation, while POMRs, SOAP notes, and FORs are structured formats that require specific types of information to be included. POMRs and SOAP notes are similar in that they are problem-oriented and focus on the patient’s current problems and treatment plan, while FORs focus on the patient’s functional abilities and progress towards goals.
- The advantages of narrative notes include flexibility in documentation and the ability to document subjective information. The disadvantages include the potential for inconsistency in documentation and the lack of structure. The advantages of POMRs, SOAP notes, and FORs include the structured format and the ability to organize information in a problem-oriented or functional manner. The disadvantages include the potential for repetition and the need to consistently follow the format.
- The S, O, A, and P portions of a SOAP note stand for subjective, objective, assessment, and plan, respectively. The subjective portion includes the patient’s reported symptoms and medical history, the objective portion includes the clinician’s observations and measurements, the assessment portion includes the clinician’s clinical judgment and diagnosis, and the plan portion includes the treatment plan and goals.
- Information provided by the patient’s family should be placed in the subjective portion of a SOAP note or in a separate section of the medical record designated for family or caregiver input.
- The FOR and SOAP format can be used together by incorporating functional outcome measures into the assessment portion of a SOAP note and using the SOAP format to