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6,7,8. Documentation Why is Documentation Important? 1. Legal Considerations a. Patient care notes are legal documents for 7 years after treatment is terminated 2. Communications a. With 3rd party payers, other PTs/healthcare workers, may assist with follow-up c...

6,7,8. Documentation Why is Documentation Important? 1. Legal Considerations a. Patient care notes are legal documents for 7 years after treatment is terminated 2. Communications a. With 3rd party payers, other PTs/healthcare workers, may assist with follow-up care in other disciplines 3. Reimbursement a. Medicare and insurance companies make decisions based on therapy notes 4. Discharge Planning a. Social workers, 3rd party payers use these notes to decide whether to accept/cover a patient 5. Clinical Decision-Making a. Method of reflecting structured clinical decision making and problem solving of PT 6. Quality Assurance and Improvement a. Data gathered from patient notes helps administration evaluate metric for quality i. Ex. pre-post intervention pain levels 7. Remembering What You’ve Done with the Patient 8. Clinical Outcomes Research a. HEALTH INFORMATICS 9. Education about Scope of Practice a. Can advocate for patient 10. Compliance a. With federal, state, and local laws, statutes, and requirements Patient Client Management Patient Client Management SOAP Note Note Process History Examination Subjective Systems review tests + Objective measures Evaluation Evaluation Assessment Diagnosis Prognosis Expected outcomes Plan of Care Plan of Care Anticipated goals Interventions SOAP 1. Subjective – what the patient reports a. Current functional status, history of condition, PAIN (patient report)  b. Medical/surgical history, diagnostic imaging, meds, social history, History of Present Illness ➔ Subjective examples ◆ PMHx: HTN, DM, PVD or PAD ◆ Pt describes intermittent dull achy pain surrounding R Anterior shoulder joint at 7/10. ◆ Worse with overhead lifting and painting. Better with rest, ice and advil. ◆ Progressively worsens throughout the day and resolves to 0/10 after sleeping on their back. ◆ 10 year history of social smoking & drinking 2. Objective – measurable observations from patient examination, interventions provided documented here, patient response to interventions (i.e. pt was fatigued, pt was acutely SOB after increasing intensity) a. AROM, PROM, strength, gait, transfers, posture, reflexes, sensation, integumentary status, special tests ➔ Objective examples ◆ Passive Range of Motion (PROM): R Shoulder Flexion = 0-130o ◆ ManualMuscleTesting(MMT): Relbowflexion=3/5 ◆ Transfers: wheelchair (w/c) to bed with moderate assistance (Mod A) ◆ Gait: 100 feet with Bilateral (B) Axillary Crutches (AC) 25% Partial Weight Bearing (PWB) Right (R) Lower Extremity (LE) ◆ VAS Pain Scale (Visual Analog Scale): 6/10 3. Assessment – a. Initial visit i. Evaluation: synthesis of data/findings, a problem list, results from test and measure 1. Ex. Cervical side bending limited to 50% of normal + Spurling's Test suggestive of R cervical radiculopathy Impaired sensation in C5 dermatome ii. Diagnosis: ICF + FUNCTIONAL diagnosis 1. Ex. Pt with signs and symptoms consistent with acetabular labral tear limiting participation in competitive sports iii. Prognosis: what level of improvement is expected, how long it will take, rehab potential 1. Ex. Pt with good rehab potential and should achieve 90% resolution within 6 weeks given adherence to HEP iv. Goals 1. describe … a. Who is receiving therapy? b. What they did i. Ex. walked  c. How they did it i. Ex. with straight cane d. Assistance given i. Ex. contact guard, min assist, etc. 2. Short term – goals for next anticipated re-assessment of function a. Typically HALF WAY POINT for expected episode of care i. May be 1 week on rehab, 2 days bedside ii. Or 1 month for outpatient 3. Long term – goals anticipated by discharge of therapy a. 3 months out b. MUSt HAVE TIME FRAME INDICATED FOR BOTH TYPES i. STG can be LTG if treatment is short MUST BE ○ MEASUREABLE Of which motion? Joint? Out of how much? 2/10 pain, 5/5 MMT, 130 AROM, (-) Test ○ FUNCTIONAL How does it translate to something meaningful for the patient To allow pt to lift child without pain on indoor level surface ○ TEMPORAL Timeframe Weeks, visits, etc. ○ SPECIFIC Based on something YOU measured (strength, ROM, etc) ABCD Goals: ○ Audience: individual who will be demonstrating the behavior/attribute ○ Behavior: action or attribute being assessed ○ Condition: environmental setting where behavior will be performed ○ Degree: degree to which the attribute/behavior should be demonstrated – measurability SMART Goals: ○ Specific: based on something you measured ○ Measureable ○ Attainable ○ Realistic ○ Timely  ➔ Goal Examples: ○ Pt will increase Right shoulder strength to 5/5 for return to overhead lifting as a construction worker within 8 visits ○ Pt will report 2/10 pain at worst in R Knee with walking for 4 hours to perform job as park ranger within 3 weeks ○ Knee flexion AROM to > 125o for return to full squatting during work activities as a Kindergarten teacher within 6 sessions ○ Pt will ambulate Indep with a straight cane > 500’ on uneven surfaces for community activities within 3 days 4. Plan a. First: how often you’ll see pt, for how long b. Second: what interventions you’ll be doing with pt, plan of action (refer to MD) ➔ Plan Examples ◆ Pt will be seen 3x/wk for 4 wks; Interventions will include: US (ultrasound), Joint Mobilization, Soft Tissue Mobilization, Therapeutic Exercise, Postural Re-training, Ice. ◆ Pt will be seen 2x/day for 2 days for transfer training and gait training NWB (non weight bearing) R LE with AC (axillary crutches) ◆ Refer to headache neurologist to address dizziness ◆ Refer to dietician for diet planning ◆ Refer back to orthopedist for medical imaging follow-up Patient/Client Management Model 1. Examination a. History → Symptom investigation i. Demographic info, social history, employment, growth/dev issues, living environment, health status, social/health habits, family hx, medical hx, medications, clinical tests (MRI, EMG, CT), chief complaint ii. Obtained from patient, family, significant others, caregivers, other interested parties b. Systems Review → Limited screening of systems i. Cardiovascular/pulmonary, integumentary, musculoskeletal, neuromuscular, communication ability/affect/cognition/language style c. Tests and Measures → gathering of data about the individual i. ICF: body systems and functions, activity limitations, participation restrictions ii. Balance, anthropometric, aerobic capacity/endurance, gait, pain, posture, ROM 2. Evaluation a. PTs interpret individual’s results of tests and measures, integrate data with other info collected during PM Hx, determine a DIAGNOSIS amenable to PT management, develop plan of care  3. Diagnosis a. Physicians: use labels that identify disease, disorder, or condition at cellular, tissue, organ, or system level i. Ex. Shoulder impingement b. PTs: use labels that identify the impact of condition on function at level of the system (MOVEMENT SYSTEM) and at level of whole person i. Ex. Pt with impaired rotator cuff functioning causing subacromial impingement, pain, and limited ability to perform overhead activity 4. Prognosis/Plan of Care a. Factors influencing prognosis: i. Chronicity ii. Multi-site or multi-system involvement iii. Pre-existing systemic conditions iv. Stability of condition v. Probability of prolonged impairments, activity limitations, participation restrictions b. Future services needed, justification for future therapy c. Plan of Care specifies: i. Anticipated goals and expected outcomes ii. Direct interventions iii. Frequency of visits iv. Duration of episode of care v. Discharge plan 5. Intervention → purposeful interaction of PT and individual to produce changes in patient’s condition consistent with Diagnosis and Prognosis a. Categories: i. Patient or client instruction ii. Airway clearance techniques iii. Assistive tech iv. Biophysical agents v. Manual therapy vi. Therapeutic exercise... 6. Outcomes → results of implementing plan of care that indicate the impact on functioning a. Quantifying impact of PT intervention on functioning Coding ICD (International Classification of Diseases) - 10 codes → what diagnosis you are treating the patient for reimbursement purposes CPT (Current Procedural Terminology) Codes → billing codes to indicate what procedures were performed ○ Billed in 15 minute increments!! ○ In order to bill for 1 unit, MUST completed more than ½ of the time = 8 minutes Therapeutic Exercise: 97110  Neuromuscular Re-education: 97112 Gait Training: 97116 Effective Documentation ~ BE OBJECTIVE AND FACTUAL → Defensible Documentation Elements 1. Limit use of abbreviations 2. Date and sign all entries 3. Document legibly 4. Report functional progress towards goals regularly 5. Document at the time of the visit when possible 6. Clearly identify note types, eg, progress reports, daily notes 7. Include all related communications 8. Include missed/canceled visits 9. Demonstrate skilled care and medical necessity 10. Demonstrate discharge planning throughout the episode of care Electronic Medical Records (EMR) - Know the abbreviations Levels of assist Weight bearing status PT - Physical I - Independently FWB -Full weight Therapy S - Supervision bearing OT - Occupational Close S - Close WBAT - Weight Therapy Supervision bearing as c/o - Complaint of CG - Contact Tolerated cc - Chief Guard PWB - Partial Complaint Min A - Minimal weight Bearing QD - Once Daily Assistance BID - Twice Daily Mod A - Moderate ROM TID - Three Assistance AROM - Active Times/Day Max A - Maximal Range of Motion QID - Four Assistance AAROM - Active Times/day Dependent - Assistive Range of D/C - Dependent Assist Motion Discontinue/Discha PROM - Passive rge Assistive Devices Range of Motion Dx - Diagnosis RW - Rolling ĉ-With walker Vital Signs ŝ - Without St Cane - Straight BP - Blood N/A - Not Cane Pressure available/applicable WBQC - Wide HR - Heart Rate LE - Lower Base Quad Cane RR - Respiratory Extremities NBQC - Narrow Rate UE - Upper Base Quad Cane Temp - Extremities LC - Loftstrand Temperature SI - Sacroiliac Crutches Hx - History AC - Axillary Miscellaneous PMHx - Past Crutches pt - Patient Medical History POC - Plan of Care  BPM - Beats per HTN - DM - Diabetes minute Hypertension Mellitus CNS - Central HEP - Home CABG - Coronary Nervous System Exercise Program Artery Bypass Graft PNS - Peripheral ICU - Intensive THA - Total hip Nervous System Care Unit arthroplasty ANS - Autonomic L-Left TKR - Total knee Nervous System R - Right replacement Flex - Flexion OOB-outofbed CVA - Ext - Extension DJD - Cerebrovascular Abd - Abduction Degenerative Joint Accident Add - Adduction Disease MS - Multiple IR - Internal s/p - Status post Sclerosis Rotation DNR - Do not GI - ER- External Resuscitate Gastrointestinal Rotation ft - foot (feet) MVA - Motor ADL - Activities of h/o - history of Vehicle Accident Daily Living eval - evaluation GSW - Gun Shot AFO - Ankle Foot SOB - Shortness of Wound Orthosis breath NSAID - amb - Ambulation prn - as needed Non-Steroidal ant - anterior AK - Above Knee Anti-Inflammatory post - posterior BK - Below Knee med - medial MI - Myocardial lat - lateral Infarction 9. Community Education What is it? Group or organization’s program to: ○ Promote learning ○ Persuade individuals to improve their QOL ○ Changing/influencing Health Behavior When? In PT school, Public health orgs, businesses, schools, athletic groups Why? Prevent injury/disease Injury response Ergonomics Safety Training other professional Audience Analysis 1. Types: a. Selected: audience has been chosen by someone else to be there b. Self-selected: audience chooses to be there, themselves 2. Demographics  a. Age b. Background/experience c. Educational level d. Expected attitudes 3. Size of Audience 4. What motivates your audience? 5. Talk to THEIR interests, not yours 6. Attitudes and biases of your audience What Led to Their Health Behavior? ★ Health Behavior = Motivation + Knowledge/Skills + Physical/Social Environment GOAL: To influence as many individuals to change! Must address: ○ Knowledge/skills ○ Beliefs, biases, attitudes ○ Readiness to change ○ Barriers in the physical/social environment 10. Patient Family Education What Do We Teach? Body mechanics Diagnosis, prognosis Ergonomics Exercises Movement Posture Body Awareness Pain/Stress management, etc. Our Goal: INFLUENCE HEALTH BEHAVIOR 9 Principles for Effective Patient Education (Davis) 1. Rapport a. Facilitation skills: active listening, showing warmth, responding with info b. NLP: matching, pacing, leading, positive descriptive statements 2. Set agenda a. Note patient priorities, set goals w/ pt b. Get INFORMED CONSENT for the program i. Description of treatment provided ii. Risks vs. Benefits  iii. Time frame, cost iv. Reasonable alternative 3. Communicate a. Verbal, non-verbal, assertive, cultural competence 4. Readiness to learn a. Trans-Theoretical model, health belief model, motivational interviewing 5. Language, beliefs culture a. Language: interpretive services i. Full/partial language barriers b. Beliefs: explanatory model c. Culture: cultural competence 6. Customize a. To the patient i. Readiness for change, motivation, attitudes/beliefs, health literacy, learning style 7. Assess barriers a. Discuss goals and barriers 8. Problem solve a. Answer questions 9. Appropriate teaching sources → readable = 5th grade reading level a. Learning styles/domains b. Education level c. Health literacy Patient Education Questions Steps Home Exercises What is the 1. Watch them do it exercise/how is it without you talking done? them through it Why? How does it 2. Check them the next relate to their session problem? 3. Quiz them What should they expect/feel? How often? Postural + Functional What it is Kinesthetic Comparative Training What is the Training (KCT) prognosis? (A) The way they’re What are the options? doing it Likely outcomes of (B) Modified interventions? (A) Back to the way they’re doing it to feel the difference Family Education  When? ○ Cognitively impaired adult → still try to include patient as much as possible ○ Physically impaired adult ○ High context culture ○ Child (under 18) Considerations ○ Patient is in charge Legal adult (18 y.o. or more) with FULL COGNITION Must specify who has access to health info, who participates in decision making and tx plan ○ Family is in charge Patient not legal adult – educate parent Patient is adult but lacks cognitive ability to make health decisions Child Education Considerations ○ Motivation Try to incorporate it into play or make it a game Multiple short bouts Observe parent doing activity with child Educate to level of child ○ Adolescents/Teens Want to be treated like adults Need to be given as much of the responsibility as they can handle 11. Interprofessional Communication Why? 1. Reduce medical error ○ Ineffective communication = leading cause of preventable patient injuries and death ○ 60% medical errors, 75% resulted in death 2. Comprehensive patient care ○ Interdisciplinary teams 3. Avoid duplication/repetition of services With Who? Doctors: ○ Internal medicine, cardiology, pulmonology, cardiothoracic surgery, orthopedics, ENT, ophthalmology, gastroenterology, burn, psych, neuro, rehab medicine Other health care practitioners: ○ OT, hand therapy, RT, social work, nursing, PA, dietitians, speech Wellness practitioners: ○ Yoga instructors, pilates, personal trainers, massage therapists, acupuncturist Other:  ○ Administration, supervisors, housekeeping, language interpreters When? 1. Interprofessional rounds (Daily- acute care, weekly, biweekly) a. Discuss patient status, progress, discharge plans b. Includes PT, OT, Speech, Social Work, MD, RN, Psych (coordinator = social or md) c. Acute Rehab – Bedside i. Weekly meetings w/ medical team for all patient’s under particular doctor’s care ii. Status report from each discipline iii. Barriers to discharge identified iv. Length of stay, goals, discharge plan determined or modified d. Subacute Rehab – SNF i. Social work may lead meetings ii. Longer length of stay, some detached to Long Term Care (nursing home) Advantages: Patients ○ Improves outcomes ○ Addresses broad needs ○ Improved patient satisfaction ○ Efficient use of time/resources ○ Efficient delivery of care ○ Facilitate continuous quality improvement ○ Challenges norms/values of each discipline Limitations Team formation ○ Time consuming, matching schedules of all involved Collaboration requires time ○ Less time for patients Successful team requires ongoing conflict resolution, goal re-assessment Failure of any of the above = impaired health care delivery Essential Communications Inpatient Hospital Units ○ Nursing: patients left in/out of bed, ambulation/transfers, pain level, safety issues ○ Physicians: WB status/precautions, pain management, change in mental status, discharge ○ Social Work: barriers to discharge, recommended home care, equipment recs Outpatient ○ Orthopedics: clarify precautions, permission to progress program, requesting modalities/meds, suspicion of further pathology  ○ Neurology: change in mental status, change/intensification of neurological signs and symptoms ○ Pediatrics: school setting, communicate w/ teachers, social work, psych, OT, parents, supervising physicians Schwartz Center Rounds Regularly scheduled times during day for health care providers to openly and honestly discuss social/emotional issues that arise in caring for patients Caregivers report: ○ Improved emotional insight ○ Improved patient compassion ○ Improved readiness to respond to patient families ○ Improved appreciation of different roles/contributions of diff professions ○ Decreased stress and isolation 12. Learning Theory and Styles Role as Educator is to Reflect on 1. Learning Domains a. Cognitive i. Knowledge and development of intellectual skills 1. Recall + recognition 2. Development of intellectual abilities and skills 3. Stating procedural patterns ii. Ex. Which exercise will you do first? Tell me what you will do. Show me (combined with psychomotor) b. Affective i. The manner in which we deal with things emotionally 1. Feelings 2. Values 3. Appreciation 4. Attitudes 5. Motivations 6. Enthusiasm ii. Observe person’s participation in the clinic, judge by patient’s behavior: if pt did recommended program at home, comments they make c. Psychomotor i. Movement based learning ii. Ex. Needs guidance, can plan movement, self-corrects errors in movement, combines movements to complete a task, changes movements suitable to a changing situation 2. Learning Theories  a. Behaviorism i. 3 assumptions: 1. Learning is manifested by a change in behavior 2. Environment shapes behavior 3. Principles of contiguity: how close 2 events must be in time for a bond to be formed ii. Classical Conditioning → behavior becomes reflex response to stimulus Ex. Pavlov’s dog 1. Involuntary response + stimulus iii. Operant Conditioning → reinforcement of behavior with reward or punishment, that enforces behavior occurring or not occurring Ex. Yes vs. No or Correct vs. Wrong 1. Voluntary behavior + consequence b. Cognitivism → “Brain Based Learning” i. Learning viewed as internal mental processes ii. 2 key assumptions: 1. Memory system is active, organized processor of info 2. Prior knowledge plays an important role in learning c. Multiple Intelligences i. 8 diff ways people understand the world 1. Linguistic: spoken, written words 2. Logical/math: inductive/deductive thinking 3. Visual spatial: visualizes objects + spatial dimensions 4. Body-kinesthetic: body and ability to control physical motion 5. Musical-rhythmic 6. Interpersonal 7. Intrapersonal 8. Naturalist d. Humanism e. Constructivism f. Right brain/Left brain 3. Learning Styles a. Four Learning Styles (Gregoric) i. Concrete Sequential 1. Learners prefer direct hands-on experience ii. Abstract Random 1. Learners have capacity to sense moods and use intuition to their advantage iii. Abstract Sequential 1. Learners have excellent abilities with written, verbal, and image symbols iv. Concrete Random 1. Like to experiment using trial and error approach 4. Learning Progression Over Time Forms of Learning 1. Explicit a. Declarative Learning i. Good recall of facts + events ii. Good recognition and recall iii. Requires attention, awareness, and reflection 2. Implicit a. Associative i. Classical conditioning = involuntary + stimulus ii. Operant conditioning = voluntary + consequence b. Non-associative i. Habituation: decreased responsiveness as a result of a repeated exposure to a stimulus 1. Ex. Lifeguard habituates to sound of whistle ii. Sensitization: increased responsiveness to a threatening or noxious stimuli 1. Ex. Pain whenever PT mobilizes knee of pt post operation c. Procedural i. Acquiring skill through physical practice without conscious attention or awareness 1. Develops through repetition 2. Observe changes in a skilled task related to baseline ii. 10,000 hours of purposeful practice considered an expert Bloom’s Taxonomy (KCA AES) 1. Knowledge: recalling information 2. Comprehension: deeper level of learning, understanding to explain 3. Application: applying the information on practicals, in the clinic 4. Analysis: looking deeper into content, how well is the treatment effective  5. Evaluation: evaluate how things are done on a global scale 6. Synthesis: creating research/knowledge based on a basic concept Motor Learning 1. Fitts and Posner Three Stage Model a. Cognitive i. Requires high degree of cognitive attention ii. Discovering requirements of and developing strategies to address a task iii. LARGE VARIABILITY IN PERFORMANCE → LOTS OF ERROR iv. Ends with large improvements in performance b. Associative i. Best strategy identified ii. Beginning to refine the skill iii. Less variability iv. Improvement is very slow c. Autonomous i. Consistent, automatic performance ii. Less cognitive control needed iii. Working on improving efficiency iv. Can layer on secondary skills 1. Ex. Signing while playing an instrument, talking while performing the skill v. Where expertise can be formed → 10,000 hours! 2. Theoretical Model of Motor Learning Psychomotor Learning: Massed vs. Distributed 1. Massed a. Longer practice sessions with many practice trials during sessions 2. Distributed a. Few practice sessions in shorter trial sessions