Documentation Basics : A Guide for the Physical Therapist Assistant

by Erickson, Mia; McKnight, Becky

• ISBN13: 9781556426735
• ISBN10: 1556426739
• Format: Paperback
• Copyright: 2005-02-24
• Publisher: Slack Incorporated

Summary

Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. Necessary for both students and clinicians,Documentation Basics: A Guide for the Physical Therapist Assistantwill teach and explain physical therapy documentation from A to Z.Documentation Basics: A Guide for the Physical Therapist Assistantcovers all of the fundamentals for prospective physical therapist assistants preparing to work in the clinic or clinicians looking to refine and update their skills. Mia Erickson and Becky McKnight have also integrated throughout the text theAPTA's Guide to PT Practiceto provide up-to-date information on the topics integral for proper documentation. What's Inside: Overview of documentation Types of documentation Guidelines for documenting Overview of the PTA's role in patient/client management, from the patient's point of entry to discharge How to write progress notes How to use the PT's initial examinations, evaluations, and plan of care when writing progress notes Legal matters related to documentation Reimbursement basics and documentation requirementsThe text also contains a section titled "SOAP Notes Across the Curriculum," or SNAC. This section provides sample scenarios and practice opportunities for PTA students that can be used in a variety of courses throughout a PTA program. These include: Goniometry Range of motion exercises Wound care Stroke Spinal cord injury AmputationEnter the physical therapy profession confidently withDocumentation Basics: A Guide for the Physical Therapist Assistantby your side.

Author Biography

Mia L. Erickson, PT, EdD, ATC, CHT
Dr. Erickson is the former Program Director of the Physical Therapist Assistant Program at Allegany College of Maryland. Currently she is an Assistant Professor and Co-Academic Coordinator of Clinical Education at West Virginia University. She has a Bachelor’s Degree in Secondary Education and Athletic Training from West Virginia University and a Master of Science Degree in Physical Therapy from the University of Indianapolis. She completed her doctoral work at West Virginia University with emphasis in curriculum and instruction. She maintains clinical practice in the areas of outpatient orthopedics and hand rehabilitation.
Becky McKnight, PT, MS
Ms. McKnight is currently the Program Coordinator of the Physical Therapist Assistant Program at Ozarks Technical Community College. She received a Bachelor’s Degree in Physical Therapy from St. Louis University and a post-professional Master’s Degree in Physical Therapy from Rocky Mountain University of Health Professions. She has also been an Academic Coordinator of Clinical Education at Ozarks Technical Community College. She maintains clinical practice and teaching responsibilities in the areas of neurology and geriatrics.

Table of Contents

Acknowledgments	ix
About the Authors	xi
Preface	xiii
Physical Therapy and Disablement	1	(10)
Mia L. Erickson
Chapter Objectives	1	(1)
Defining Health and Disability	1	(3)
International Classification of Functioning, Disability, and Health	2	(1)
The Nagi Framework	2	(2)
Physical Therapy and Disablement: Putting it all Together	4	(1)
Disablement and Documentation	4	(2)
Review Questions	6	(2)
Application Exercises	8	(3)
Reasons for Documenting	11	(10)
Mia L. Erickson
Chapter Objectives	11	(1)
Overview	11	(1)
Reasons for Documenting	12	(3)
Record Patient Data	12	(1)
Demonstrate the Clinical Decision-Making Process	13	(1)
Provide Proof of Medical Necessity	13	(1)
Provide Proof of Skilled Care	14	(1)
The Event of Legal Action	14	(1)
Review Questions	15	(1)
Application Exercises	16	(5)
Documentation Formats	21	(12)
Mia L. Erickson
Chapter Objectives	21	(1)
Narrative	21	(1)
Problem-Oriented Medical Record	22	(1)
SOAP Notes	23	(2)
Functional Outcomes Reporting (FOR)	25	(1)
Templates and Fill-in Forms	26	(1)
Computerized Documentation	27	(1)
Review Questions	28	(2)
Application Exercises	30	(3)
The Physical Therapy Process	33	(18)
Becky McKnight
Chapter Objectives	33	(1)
Introduction	33	(1)
The Physical Therapy Process	34	(2)
Patient Point of Entry	34	(1)
The Patient/Client Management Model	34	(2)
Physical Therapist and Physical Therapist Assistant Roles	36	(1)
Coordination, Communication, and Documentation	37	(1)
Utilizing the Physical Therapy Documentation	37	(5)
SOAP Initial Evaluative Note	38	(2)
How to Use the Initial Evaluative Note	40	(2)
Review Questions	42	(1)
Application Exercises	43	(8)
Documentation Practice	51	(24)
Becky McKnight
Mia L. Erickson
Chapter Objectives	51	(1)
Documentation in Physical Therapy	51	(1)
Basic Principles	52	(1)
Documenting Patient Care	53	(12)
Informed Consent	55	(1)
Problem (P)	55	(1)
Subjective (S)	55	(1)
Objective (O)	56	(5)
Assessment (A)	61	(2)
Plan (P)	63	(2)
Review Questions	65	(1)
Application Exercises	66	(9)
Reimbursement Basics	75	(10)
Mia L. Erickson
Chapter Objectives	75	(1)
What is Reimbursement?	75	(1)
Types of Insurance	75	(4)
Social Insurance	76	(2)
Managed Care	78	(1)
Casualty Insurance	79	(1)
Indemnity Insurance	79	(1)
Documentation and Reimbursement	79	(2)
Review Questions	81	(2)
Application Exercises	83	(2)
Legal and Ethical Considerations for Physical Therapy Documentation	85	(8)
Mia L. Erickson
Chapter Objectives	85	(1)
Introduction	85	(1)
Patient Privacy and Confidentiality	85	(2)
The Privacy Act of 1974 (5 U.S.C. § 552a)	85	(1)
Health Insurance Portability and Accountability Act	86	(1)
Privacy and State Law	86	(1)
Privacy Recommendations and Computerized Documentation	86	(1)
Privacy and Ethics	86	(1)
Fraud and Abuse	87	(1)
Risk Management	87	(1)
Establishing Documentation Requirements	87	(2)
Federal Agencies	87	(1)
State Practice Acts	88	(1)
American Physical Therapy Association	88	(1)
Review Questions	89	(4)
SOAP Notes Across the Curriculum	93	(24)
Goniometry	94	(1)
Strength Assessment	95	(1)
Range of Motion Exercises	96	(1)
Transfers	97	(2)
Tilt Table	99	(1)
Wheelchairs	100	(1)
Gait Training	101	(2)
Wound Care	103	(1)
Chronic Obstructive Pulmonary Disease/Vital Signs	104	(1)
Traumatic Brain Injury	105	(1)
Cerebrovascular Accident	106	(2)
Lower Extremity Amputation/Prosthetic Devices	108	(3)
Musculoskeletal Trauma	111	(2)
Pediatrics/Orthotic Devices	113	(4)
Glossary	117	(6)
Appendix A: Abbreviations and Symbols	123	(8)
Appendix B: Sample Forms and Templates	131	(14)
Jeff Erickson
References	145	(6)
Index	151