Documentation Basics for the Physical Therapist Assistant

Third Edition

Core Texts for PTA Education

Third Edition

Documentation Basics for the Physical Therapist Assistant

Core Texts for PTA Education

MIA L. ERICKSON, PT, EDD, CHT, ATC Midwestern University

Physical Therapy Department Glendale, AZ

REBECCA MCKNIGHT, PT, MS Educational Consultant Reach Consulting, LLC

Forsyth, MO

www.Healio.com/books

Dr. Mia L. Erickson and Rebecca McKnight have no financial or proprietary interest in the materials presented herein.

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CONTENTS About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Chapter 1 Disablement and Physical Therapy Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 2 The Physical Therapy Episode of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Rebecca McKnight, PT, MS

Chapter 3 Reasons for Documenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 4 Documentation Formats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 5 Electronic Medical Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 6 Basic Guidelines for Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Rebecca McKnight, PT, MS and Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 7 Interpreting the Physical Therapist Initial Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Rebecca McKnight, PT, MS

Chapter 8 Writing the Subjective Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Rebecca McKnight, PT, MS

Chapter 9 Writing the Objective Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Rebecca McKnight, PT, MS

Chapter 10 Writing the Assessment and Plan Sections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Rebecca McKnight, PT, MS

Chapter 11 Payment Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 12 Legal and Ethical Considerations for Physical Therapy Documentation . . . . . . . . . . . . . . . . 119 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 13 Documentation Across the Curriculum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Mia L. Erickson, PT, EdD, CHT, ATC

Traumatic Brain Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Tracy Rice, PT, MPH, NCS

Spinal Cord Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Tracy Rice, PT, MPH, NCS

Appendix: Abbreviations and Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155

ABOUT THE AUTHORS Mia L. Erickson, PT, EdD, CHT, ATC, is a faculty member in the Physical Therapy Department at Midwestern

University in Glendale, AZ. Mia earned a bachelor’s degree from West Virginia University in secondary education in 1994 and a master of science degree in physical therapy from the University of Indianapolis in 1996. Mia earned a doctoral degree in education from West Virginia University with an emphasis on curriculum and instruction in 2002. Her clinical practice is in the area of hand and upper-extremity rehabilitation.

Rebecca McKnight, PT, MS, received her bachelor of science degree in physical therapy from St. Louis University in 1992 and her postprofessional master of science degree from Rocky Mountain University of Health Professions in 1999. She taught at Ozarks Technical Community College for 14 years, serving as Program Director for 9 of those years. Rebecca is an active member of the American Physical Therapy Association and is a former chair of the Physical Therapist Assistant Educators Special Interest Group of the education section. Rebecca has spoken at many national meetings on physical therapist assistant curriculum design and programmatic assessment. She is the 2009 recipient of the F.A. Davis Award for Outstanding Physical Therapist Assistant Educator. Rebecca has been providing educational consultation in the areas of curriculum design, development, and assessment for physical therapist assistant programs nationwide since 2007.

PREFACE We would like to thank you for choosing the Third Edition of Documentation Basics for the Physical Therapist Assistant.

We think that you will find some substantial changes that make this edition more modern, reflecting contemporary prin- ciples in documentation. Two of the biggest changes are incorporation of the International Classification of Functioning, Disability and Health (ICF) disablement model (vs other models that have been discussed in previous editions) and further integration of the electronic medical record. The ICF serves as the framework for several important aspects of this text. Throughout, we encourage readers to really think about disablement and disablement concepts when writing notes. This includes documenting impairments in body structure and function in addition to activity limitations and participation restriction. We also encourage the reader to frequently note improvements in impairments, activity limitations, and par- ticipation restrictions brought on by the intervention provided in objective terms so that others reading the documentation can see the improvement.

This edition has been updated in its discussion of the electronic medical record. In addition to describing the differ- ences in documentation methods using a computer vs a paper chart, this edition features a stand-alone chapter on the electronic medical record. It walks the reader through differences in the electronic health and medical records and dis- cusses the rationale for change to electronic record keeping. The book also incorporates some evidence tied to benefits and challenges of computerized documentation. We were fortunate enough to have WebPT® (Phoenix, AZ) allow us to integrate screen shots from its computerized documentation system. This enables the reader to see what a screen would look like in various parts of the medical record.

We continue to incorporate concepts related to documenting the rationale for treatment and note how the unique skills of the physical therapist assistant were used in patient management. Examples, or “how-tos,” are also provided. We feel like these changes are unique to our text and can help readers to understand these important aspects of documentation in today’s payer system.

While we continue our instruction in writing a note using the SOAP (subjective, objective, assessment, and plan) struc- ture, we recognize and point out its flaws. We still believe that understanding parts of notes using the SOAP acronym can help students to learn the fundamentals and then, when they get to the clinical site, they can integrate their knowledge into the software or charting system used at that site.

Again, we are happy to provide you with this updated version of our book, and we hope that you enjoy it, whether you are using it as a physical therapist assistant student, a physical therapist assistant educator, or a clinician.

Mia L. Erickson, PT, EdD, CHT, ATC

Erickson ML, McKnight R. Documentation Basics for the Physical Therapist Assistant, Third Edition (pp. 1-7)

Disablement and Physical Therapy Documentation

Chapter 1

After reading this chapter, the reader will be able to do the following: 1. Define disablement. 2. Define terminology used in the International

Classification of Functioning, Disability and Health (ICF).

3. Differentiate between impairment, activity limitation, and participation restriction.

4. Define documentation. 5. Describe the need for common language in physical

therapy documentation. 6. Describe how disablement concepts can be integrated

into physical therapy documentation. A traditional approach to defining a person’s health

comes from the biomedical model in which health means free or absent from disease.1 The biomedical model implies that accurate diagnosis and identification of the patient’s biological defects can directly lead to selection of interven- tions that will maximize health outcomes.1 In this model, however, there is little emphasis on how the disease affects

the person’s ability to function or participate within society on a daily basis. Over the last few decades, many reha- bilitation professionals have shifted their focus away from managing the disease or pathology and have moved toward managing the consequences of the disease or condition. It has become more common to focus on these consequences as they pertain to the individual’s ability to carry out tasks and function within society. Assessing functional perfor- mance and describing functional status are now primary components of the physical therapist’s examination of the patient. Verbrugge and Jette2 described the consequences that chronic and acute conditions have on specific body system function and on a person’s ability to act in neces- sary, usual, expected, and personally desired ways in his or her society as disablement. These authors explained that disablement is a “process,” indicating that it is dynamic, or a trajectory of functional consequences over time. A more contemporary approach to physical therapy patient man- agement is to incorporate disablement and disablement concepts.

Individuals and groups throughout the world have developed disablement frameworks. Disablement frame- works are useful for providing a common language for health care providers, and they can serve as a basic archi-

CHAPTER OBJECTIVES

KEY ABBREVIATIONS APTA | ICD-10 | ICF | PT | WHO

Chapter 12

tecture for research, policy, and clinical care.2 In addi- tion to providing infrastructure, disablement frameworks define health in terms that go beyond the patient’s medical diagnosis or disease, acknowledging the importance of societal, psychological, and physical functioning. Rather than placing the measure of health on the disease process itself, these models have helped providers to shift toward understanding an individual’s ability to carry out neces- sary life tasks and to function within society. Disablement frameworks have attempted to delineate a pathway from pathology to functional outcome while recognizing the social, psychological, and environmental factors that can facilitate or interfere with the pathway.2 The purpose of this chapter is to introduce you to the disablement frame- work used in physical therapy practice and to introduce the purpose of using disablement and disablement concepts in clinical documentation.

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH

The ICF, originally known as the International Classification of Impairments, Disabilities, and Handicaps, was endorsed by the 54th World Health Assembly and released in 2001. The ICF provides a uniform, standard language for describing an individual’s health and health- related state that moves beyond his or her diagnosis.3 In 2008, the American Physical Therapy Association (APTA) House of Delegates voted to endorse the ICF and, as a result, APTA publications, documents, and communications have been updated to incorporate the ICF language (Example 1-1).4 Therefore, the ICF serves to provide a common lan- guage for physical therapists to communicate.

Example 1-1 The following definitions have been endorsed by the World Health Organization as part of the ICF3:

• Functioning is an umbrella term that includes all body functions, activities, and participation. • Disability serves as an umbrella term for dysfunction at any one or more of the following levels: impairment, activity limitation, and participation restriction.

• Body functions are physiological functions of the body (including psychological function). • Body structures are anatomical bodily structures, such as organs and limbs. • Impairments are problems with body functions (physiological, psychological) or structures, such as a deviation or loss.

• Activity is the execution of a task or activity by an individual. • Activity limitations are difficulties that might be encountered by an individual who is attempting to complete a task or carry out an activity.

• Participation is involvement in a life situation, such as work or school. • Participation restrictions are problems an individual might face while involved in life situations.

• Contextual factors are the complete factors that make up a person’s life and living, including his or her background.

• Environmental factors are the physical, social, and attitudinal environmental in which people live and carry out their lives. These include things immediate to the individual, such as his or her home or workplace, and the larger social context, such as government agencies designed to assist people with disabilities.

• Personal factors are factors specific to the individual and his or her background. These include things such as age, gender, social habits, health habits, upbringing, and coping strategies.

Disablement and Physical Therapy Documentation 3

In the ICF, the individual’s health or health-related state is described in terms of function and disability. What the individual can do is known as functioning, or the positive aspects of health. What the individual cannot do is known as disability, or the negative aspects of health (Figure 1-1).3 Function and disability comprise Part 1 of the ICF. Part 1 is further divided into the following 2 components: (1) body functions (physiological function) and body struc- tures (anatomical structures) and (2) activities and partici- pation (Figure 1-2).3 In categorizing an individual’s health according to the ICF, a health care provider would describe body structures and functions that are intact and those that are not intact. Any deviation(s) from normal body structure and/or function are known as impairments. For the activities and participation component, the exam- iner identifies functional tasks that the individual can do (known as activities) and those that he or she cannot do (known as activity limitations). The examiner also identi-

fies life roles that the individual can carry out (known as participation) and those that he or she cannot carry out (known as participation restrictions; see Figure 1-1).3

The ICF also accounts for contextual factors that might facilitate or impede the patient’s function. These appear in Part 2, which also includes environmental and personal factors that affect the individual’s functioning and dis- ability. Environmental factors are external factors that are either within the individual’s immediate environment or part of a larger social structure and that affect the individual’s ability to participate in society. These might be facilitators, which enhance participation, or barriers, which deter participation. Environmental factors include things such as physical structures (eg, ramps, stairs, curbs). Personal factors are those that are unique to the individual, such as attitude, mood, or family support (see Figure 1-2).3

Figure 1-1. Overview of the International Classification of Functioning, Disability and Health.3 The string of boxes on the left repre- sents the positive aspects of the health state or condition. The string of boxes on the right rep- resents deviations from normal, or the negative aspects of health.

Body-level

Individual- level

Societal- level

ICF

Health and Health- Related States

Function: What the individual

CAN do (Positive Aspects of

Health)

Disability: What the individual

CANNOT do (Negative Aspects

of Health)

Body tissues and/ or structures that

are intact and functioning

(Normal)

Body tissues and/ or structures that are not intact or

functioning (Impairments)

Tasks an individual CAN carry out

(Activities)

Tasks an individual CANNOT carry out

(Activity Limitations)

Roles in which an individual CAN

participate (Participation)

Roles in which an individual CANNOT

participate (Participation Restrictions)

Chapter 14

The ICF is part of a “family” of classifications created by the World Health Organization (WHO) known as the WHO Family of International Classifications.5 This family also includes the International Classification of Diseases, Tenth Revision (ICD-10), a classification system for medical diagnoses and diseases. The ICD-10 is the diagnostic clas- sification standard for all clinical and research purposes. It defines the universe of disease, disorders, injuries, and other related health conditions, listed in a comprehensive format.6 The ICF and ICD-10 are meant to complement each other in that the ICD-10 provides a catalog of medical diagnoses, diseases, disorders, and health conditions and the ICF provides corresponding information on function and disability. Used together, they provide a broader picture of an individual’s health.7

PHYSICAL THERAPY AND DISABLEMENT The ICF provides clinicians with standardized termi-

nology and a framework to aid in exploring the impact of disease or injury on an individual’s daily life. More spe- cifically, physical therapy providers can use the ICF to help understand the consequences of the disease or condition on the body systems and the impact on the individual’s activ- ity level and participation within society. Consideration

of disablement when working with patients helps physical therapy providers to realize more complex functional and social issues that patients face.

Individuals in need of physical therapy services often have a disease or injury with resulting impairments in body structure(s) and/or function(s), activity limitations, and participation restrictions that are identified during the physical therapist’s examination. Impairments can be limitations in range of motion, strength, endurance, or balance, to name a few. But to see how the patient’s abil- ity to participate in society has been compromised, the examination must go beyond the impairment level. It is our responsibility to understand how impairments affect the patient’s day-to-day activities and participation in a variety of settings and situations; therefore, the physical therapist’s examination of patient function includes assessment of the following: (1) activities such as bed mobility, transfers, hygiene, self-care, and home management (eg, yardwork, household cleaning); and (2) participation such as the abil- ity to work, go to school, play, and participate in commu- nity activities (eg, going to the grocery store or bank). By understanding an individual’s impairments and his or her activity limitations and participation restrictions, we can better understand the degree of disability associated with the pathology for the individual patient.

Figure 1-2. The International Classification of Functioning, Disability and Health3 from the WHO. (Reprinted with permis- sion from the WHO.)

Disablement and Physical Therapy Documentation 5

DOCUMENTATION AND DISABLEMENT Documentation, otherwise known as medical record

keeping, has been defined as “any entry into the individu- al’s health record, such as a(n) consultation reports, initial examination reports, progress notes, flow sheets, checklists, re-examination reports, or summations of care, that identi- fies the care or services and the individual’s response to intervention.”8 Complete documentation also includes the physician prescription(s) and certification(s), communica- tion with other care providers, copies of exercise programs or patient instructions, and any other disciplines’ notes or comments that support the interventions.9

As you will read in subsequent chapters, documenta- tion will serve many purposes, but, regardless of the pur- pose, your documentation should reflect disablement. One reason for integrating disablement concepts in physical therapy documentation is to achieve consistency in termi- nology because our notes are the sole record of the episode of care provided to each patient or client. Another reason is to show the reader how the patient’s pathology and impair- ments influence his or her activities and participation in daily life. Disablement concepts serve as a foundation for this text. Throughout the chapters, you will be reminded of the following 3 important disablement concepts that should be integrated into your clinical documentation: 1. Documentation should reflect not only measures of

impairment, but also measures of activity limitations and participation restrictions.

2. Documentation should describe how the patient’s impairments relate or contribute to his or her activity limitations and participation restrictions.

3. Documentation should explain how physical therapy interventions are bringing about changes in impair- ments, activity limitations, and participation restric- tions that relate to the patient’s therapy goals.

REFERENCES 1. MacDermid JC, Law M, Michlovitz SL. Outcome mea-

surement in evidence-based rehabilitation. In: Law M, MacDermid JC, eds. Evidence-Based Rehabilitation: A Guide to Practice. 3rd ed. Thorofare, NJ: SLACK Incorporated; 2014:65-104.

2. Verbrugge LM, Jette AM. The disablement process. Soc Sci Med. 1994;38(1):1-14.

3. World Health Organization. International Classification of Functioning, Disability and Health: ICF. Geneva: World Health Organization; 2001.

4. American Physical Therapy Association. International Classification of Functioning, Disability, and Health. APTA Website. http://www.apta.org/ICF/. Updated August 23, 2013. Accessed October 24, 2016.

5. Madden R, Sykes C, Ustun TB. World Health Organization Family of International Classifications: definition, scope, and purpose. World Health Organization Website. http://www. who.int/classifications/en/FamilyDocument2007.pdf?ua=1. Updated February 2, 2012. Accessed October 24, 2016.

6. World Health Organization. Classifications: International Classification of Disease. WHO Website. http://www.who. int/classifications/icd/en/. Updated June 29, 2016. Accessed October 24, 2016.

7. Escorpizo R, Bemis-Dougherty A. Introduction to spe- cial issue: a review of the International Classification of Functioning, Disability and Health and physical therapy over the years. Physiother Res Int. 2015;20(4):200-209.

8. American Physical Therapy Association. Guide to Physical Therapist Practice 3.0. APTA Website. http://guidetoptprac- tice.apta.org/content/1/SEC2.body. Updated August 1, 2014. Accessed October 24, 2016.

9. Redgate N, Foto M. Pay by the rules: avoid Medicare audits and reduce payment denials with a sound strategy and prop- er documentation. Physical Therapy Products. 2003;October/ November:28-30.

Chapter 16

REVIEW QUESTIONS 1. How is a person’s health determined today as opposed to 5 decades ago?

2. In your own words, describe disablement.

3. According to the ICF, what is the difference between an impairment, an activity limitation, and a participation restriction?

4. Why is there a need for disablement models today? Why are they important to you?

5. What is physical therapy documentation? What does it include?

6. Give some examples of ways a physical therapist assistant can incorporate disablement concepts into his or her documentation.

7. Look at the examples below. Determine if each would be considered an impairment in body function or structure, an activity limitation, or a participation restriction.

Taking a bath Going to school Brushing teeth Limited shoulder motion Walking in the community Going to the grocery store Ascending/descending stairs Turning a door knob Poor endurance Writing Working Poor balance Donning socks Bathing

Disablement and Physical Therapy Documentation 7

Read the following scenarios and identify the impairments, activity limitations and participation restrictions.

8. You are working with a 70-year-old male who had a total hip replacement 3 weeks ago. He is now able to move in and out of the bed independently, transfer to a chair placed at the bedside, and ambulate 25 feet with a standard walker. He wants to return to driving, golfing, and playing with his grandchildren.

9. You are working with a 10-year-old female in the school system. Her medical diagnosis (pathology) is spastic diple- gia cerebral palsy. You have been working on ambulating up and down the stairs (which she can perform with min- imum assist of 1, a quad cane, and a handrail) and increasing the speed of her gait. At the present time, she leaves her classes early so that she can make it to the next one on time, and she uses the elevator rather than the stairs.

10. Your patient is a 15-year-old who sustained a traumatic closed head injury in a motorcycle accident. He is confused and disoriented, and he requires constant supervision for his safety. He can walk and get in and out of bed with supervision. He can also ascend and descend stairs with supervision. He is unable to work.

Rebecca McKnight, PT, MS

Erickson ML, McKnight R. Documentation Basics for the Physical Therapist Assistant, Third Edition (pp. 9-18)

The Physical Therapy Episode of Care

Chapter 2

After reading this chapter, the reader will be able to do the following: 1. Describe a physical therapy episode of care from point

of entry to discontinuation of services. 2. Discuss the various ways patients access a physical

therapist for care. 3. List the 6 elements of the Patient/Client Management

Model. 4. Define and describe each of the 6 elements of the

Patient/Client Management Model. 5. Discuss the roles of the physical therapist and physi-

cal therapist assistant within the Patient/Client Management Model.

6. Describe the physical therapist assistant’s responsibili- ties related to patient care, documentation, and com- munication.

Sadie had come to terms with the fact that she has mul- tiple sclerosis. After all, she had witnessed her aunt Linda, who also was diagnosed with multiple sclerosis, living a fruitful and productive life even though she had to make some changes in her daily routine. This did not, however,

keep Sadie from getting frustrated with some of the new issues she had to face. Most recently, she had been experienc- ing fatigue, which had been hindering her ability to function at work. Even more frustrating than the fatigue were the new symptoms of clumsiness affecting her arms and legs and causing her difficulty with most of her activities. Upon her neurologist’s suggestion, Sadie had been admitted to the local hospital for treatment. After returning home from the hospital, Sadie was still experiencing difficulties with her daily tasks. Her neurologist recommended that Sadie seek a physical therapist to address her coordination and balance issues. Sadie sat in front of her computer with a list of physi- cal therapists in the area and began to research each physical therapist to see whether any had experience with working with individuals with her problems.

To actively participate in the provision of physical therapy services efficiently and with confidence, you must start with an understanding of the entire physical therapy care process. This will enable you to appreciate the role that you will play in the provision of interventions and the role of your supervising physical therapist(s). Based upon this understanding, you will begin to grasp how integral communication is to the entire process and how essen- tial effective documentation is in ensuring that patients

CHAPTER OBJECTIVES

Chapter 210

“receive appropriate, comprehensive, efficient, and effective quality care.”1 This chapter examines how patients access physical therapy services. We provide a general outline of components of physical therapy care throughout an episode of care. We then take a close look at the American Physical Therapy Association (APTA) Patient/Client Management Model and the roles of the physical therapist and physical therapist assistant within the components of the model. Finally, we touch on the relationship between the Patient/ Client Management Model and documentation, providing the foundation for upcoming chapters.

PHYSICAL THERAPIST SERVICES The APTA Guide to Physical Therapist Practice1 outlines

the physical therapy process by means of the Patient/Client Management Model. This model defines and describes 6 elements required to ensure that optimal physical therapy care occurs during a patient’s episode of care. These essen- tial components include examination, evaluation, diagno- sis, prognosis, intervention, and outcomes (Table 2-1)1. We will look at each of these components in more detail, but first we need to consider how patients/clients access a physi- cal therapist to receive care.

Patient Point of Entry Individuals enter physical therapy care by either self-

referral or when referred by another health care practi- tioner. Self-referral, also known as direct access, is when an individual seeks care from a physical therapist with- out first obtaining a referral from another primary care provider, such as a physician. Currently, all state practice acts allow a physical therapist to perform an evaluation and provide some form of treatment without a physi- cian referral.2 However, most states still have restrictions that limit what care the physical therapist can provide in the absence of meeting additional conditions. As of June 2016, only 18 states allow unrestricted access to physical therapy services. Unrestricted access is when there are no legal restrictions or additional conditions required of a physical therapist to provide all aspects of patient/cli- ent management. The level of patient access to physical therapy services and types of restrictions per state law can be viewed in the APTA document Levels of Patient Access to Physical Therapist Services in the States: http://www. apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/ Direct_Access/DirectAccessbyState.pdf.

In addition to self-referral, patients access a physical therapist when referred by another health care provider. Depending on state regulations, physical therapists can receive referrals from physicians, physician assistants, chi- ropractors, nurse practitioners, midwives, and dentists. Often, patients initially access physical therapy services during a hospitalization for disease or injury. At other

times, individuals will enter physical therapy care through outpatient services, home health services, or school-based services.

The Patient/Client Management Model Once an individual has accessed a physical therapist,

the therapist will initiate the episode of care through the examination/evaluation process. This process must be initi- ated prior to the provision of any interventions. During the examination, the physical therapist collects data that will be used in determining appropriate management strate- gies. The mental process of analyzing the data and making clinical decisions based upon the information is referred to as the evaluation. As part of the evaluation, the physi- cal therapist will determine a physical therapy diagnosis, the patient’s prognosis for achieving expected outcomes, and what intervention strategies will be implemented. Once interventions are initiated, the physical therapist will monitor the patient’s progress through a review of his or her outcomes. Let’s take a closer look at these elements.

Examination As indicated above, the purpose of the examination is

for the physical therapist to collect data to guide clinical decision making. An examination consists of the following 3 components: (1) history, (2) systems review, and (3) tests and measures. Patient history can be obtained from the patient or the patient’s caregiver, family, other individuals familiar with the patient’s history (eg, other health care providers, case managers, teachers, employers, significant others),1 and medical record if one is available. History data include information related to several areas, including the current condition for which the individual is seeking physical therapy services and current or past health infor- mation (Sidebar 2-1). Additionally, the physical therapist will ask about the patient’s home situation, support system, and community involvement. Patient history data allow the therapist to gain a holistic view of the individual and help to contextualize the patient’s reason for seeking physical therapy services. The information is essential for the physi- cal therapist to consider when determining the patient’s prognosis.

After obtaining a picture of the patient’s condition and concerns through history taking, the physical therapist performs a systems review. A systems review is a “hands-on examination” where the therapist performs limited exami- nation of the patient’s overall medical health by reviewing the patient’s cardiovascular/pulmonary system, integu- mentary system, musculoskeletal system, neuromuscular system, communication ability, affect, cognition, language, and learning style.3 Based on information gathered dur- ing the history and systems review, the physical therapist will select and perform appropriate tests and measures.1 Tests and measures are methods and techniques that the

The Physical Therapy Episode of Care 11

Table 2-11

Elements of the Patient/Client Management Model

Element Who/When Includes Source of Information

Purpose

Examination Performed by the physical therapist on all patients prior to provision of interventions

• History • Systems review • Tests and measures

• Medical record review

• Patient interview

• Communication with others

Provides data needed for the physical therapist to determine the plan of care

Evaluation Performed by the physical therapist in conjunction with, and based upon, the examination

• Plan of care (goals and interventions to be provided)

• Involvement of other providers

The clinical judge- ment of the physi- cal therapist based upon findings from the examination

Allows others (including the physical thera- pist assistant) insight into the anticipated level of improvement, intervention plan, and frequency and duration of services

Diagnosis Determined by the physical therapist

A label which describes the dysfunction requiring physical therapist interventions

Prognosis Determined by the physical therapist

The predicted level of improvement, treatment goals, expected outcomes, duration and frequency of treatment and interventions to be used

Intervention Done by the physical therapist or physical therapist assistant (as directed) to produce the changes in the patient’s condition

• Patient or client instruction

• Airway clearance techniques

• Assistive technology • Biophysical agents • Functional training in self-care and domestic, work, com- munity, social, and civic life

• Integumentary repair and protection techniques

• Manual therapy techniques

• Motor function

Specific interven- tions to be provided per the categories outlined by the physical therapist in the plan of care

Decrease inflam- mation, decrease pain, increase motion, improve functional abilities, etc

Outcomes Performed by the physical therapist or the physical therapist assistant

Tests and observations consistent with initial examination

Initial examina- tion and follow-up documentation

Used to deter- mine patient response to interventions and progress toward goals

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therapist uses to gather data needed to determine the diag- nosis and prognosis and to guide clinical decision making (Sidebar 2-2). Tests and measures are also used later in patient/client management to evaluate outcomes and to note patient progression.

Evaluation The physical therapist analyzes the information gathered

during the examination process and makes clinical judg- ments about the findings. This clinical decision-making process is known as the evaluation. Evaluation is a continu- ous process. It begins with the first data gathered during the history taking and undergirds all decisions made through- out the entire episode of care; however, as a component of initiation of care, evaluation is the process that the physical therapist utilizes to determine a physical therapy diagnosis and prognosis and to establish the plan of care.

Clinical decisions made by the physical therapist include whether to initiate physical therapy care and whether there is a need for other health care provider involvement. The involvement of other health care providers can include referral, consultation, comanagement, or a combination of these. A physical therapist will choose to refer a patient when the patient’s condition requires the management of a different health care provider. This might be because

the patient has a condition that falls outside of the scope of practice of the physical therapist or it could be because the patient’s physical therapy needs fall outside of the physical therapist’s personal scope of practice (knowledge, abilities, or experience). The following are examples of each situation:

• Outside of a physical therapist’s scope of practice º During the examination, the physical therapist notes

findings consistent with congestive heart failure. The therapist refers the patient to a cardiologist so the patient can receive the necessary medical care.

Sidebar 2-1 Categories of Information Gathered in

History Portion of the Examination • Activities and participation • Current condition(s)/chief complaint(s) • Employment/work (eg, job, school, play) • Family history • Functional status and activity level • Health restoration and prevention needs • General demographics (eg, age, sex, race) • General health status • Growth and development • Living environment • Medical/surgical history • Medications • Systems review via medical chart review

including other clinical tests • Social history • Social/health habits (past and current)

Sidebar 2-2 Categories of Tests and Measures Used by

Physical Therapists • Aerobic capacity/endurance • Anthropometric characteristics • Assistive technology • Balance • Circulation • Community, social, and civic life • Cranial and peripheral nerve integrity • Education life • Environmental factors • Gait • Integumentary integrity • Joint integrity and mobility • Mental functions • Mobility • Motor function • Muscle performance • Neuromotor development and sensory

processing • Pain • Posture • Range of motion • Reflex integrity • Self-care and domestic life • Sensory integrity • Skeletal integrity • Ventilation and respiration • Work life

The Physical Therapy Episode of Care 13

• Outside of a physical therapist’s personal scope of practice

º A physical therapist’s examination reveals a vestibu- lar disorder. Although interventions for vestibular disorders fall within the physical therapy scope of practice, the therapist is aware of another therapist in the area who specializes in vestibular disorder therapy and, therefore, refers the patient to ensure that he or she receives optimal care.

Even when the physical therapist chooses to refer a patient to another care provider for services, the physical therapist is still obligated to determine whether the patient is appropriate for care and, in both scenarios above, it is possible that the therapist might retain some patient care management responsibilities. In the scenario with the patient referred to the cardiologist, the physical therapist might choose to work with the patient on energy conserva- tion techniques and modified activities of daily living while waiting for the cardiologist report. In the second scenario, the patient might also have other physical therapy problems for which the initiating physical therapist has more experi- ence and is a more-qualified professional to address. In this case, the therapists would divide the patient manage- ment based on their levels of expertise and should closely collaborate. This would be an example of comanagement described below.

In some cases, the physical therapist may choose to retain care of the patient but consult with another pro- vider due to the nature of the condition. Examples of other providers with whom the physical therapist might consult include a physician, a dentist, a nurse practitioner, a psy- chologist, an occupational therapist, or even another physi- cal therapist. It is appropriate for the physical therapist to seek the advice of any provider who can provide insight that would be beneficial to the patient. The following are 2 examples of incidents when a physical therapist consults with another provider:

• A physical therapist consults with another discipline. º A physical therapist is working with a patient with

long-term activity limitations and participation restrictions due to a cerebrovascular accident. The patient demonstrates cognitive and behavioral defi- cits that impact the patient’s ability to participate in physical therapy. The therapist consults with a neuropsychologist to determine the best strategies for patient management and to optimize interventions and ensure that the best care is provided.

• A physical therapist consults with another physical therapist.

º A physical therapist’s examination reveals a vestibu- lar disorder. Although interventions for vestibular disorders fall within the scope of practice of a physi- cal therapist, the therapist does not have any expe- rience with vestibular disorders. The patient lives in a rural area and there are no therapists in the

area with expertise in the management of patients with vestibular disorders. To ensure that the patient receives optimal care, the physical therapist consults with a physical therapist in another area who is a certified vestibular specialist.

Comanagement is a common situation in inpatient facilities and with pediatric clients. It occurs when the physical therapist shares responsibility for patient manage- ment with providers from other disciplines or with another physical therapist (as in the scenario described above). Comanagement requires collaboration and strong commu- nication due to the shared responsibility for patient care. Examples of comanagement include interdisciplinary care that is provided in an inpatient rehabilitation environment or with school-based therapy services.

When the physical therapist determines that it is appro- priate to initiate care, the therapist may directly provide some or all of the interventions or may choose to direct a physical therapist assistant to provide selected interven- tions. In the event that the physical therapist directs compo- nents of the intervention to the physical therapist assistant, the physical therapist remains responsible for all aspects of the physical therapy episode of care and is accountable for the actions of the physical therapist assistant(s).

Prior to initiating interventions, the physical therapist established a plan of care. The plan of care is developed in collaboration with the patient and is based on the examina- tion, evaluation, diagnosis, and prognosis. As indicated in the APTA Defensible Documentation materials, the plan of care includes the following3:

• Overall goals stated in functional, measurable terms that indicate the predicted level of improvement in function.

• A statement of interventions/treatments to be provided during the episode of care.

• Duration and frequency of service required to reach the goals.

• Anticipated discharge plans (may be part of the prog- nosis or written separately).

The physical therapist’s plan of care must include suc- cinct, “measurable, functionally driven, and time limited”1 goals. Goals serve as the tool to which outcomes are com- pared. This allows for the assessment of the effectiveness of the plan of care and the determination of the patient’s progress. A well-written plan of care also delineates the interventions, parameters for each intervention, purpose of the interventions, progression parameters, and, if indi- cated, precautions.

Intervention Once the plan of care has been established, direct inter-

vention can begin. As noted earlier, physical therapists may choose to provide the interventions or may direct that inter- ventions be provided by a physical therapist assistant. The Guide to Physical Therapist Practice defines interventions

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as “the purposeful interaction of the physical therapist with an individual—and, when appropriate, with other people involved in the individual’s care—to produce changes in the condition that are consistent with the diagnosis and prognosis.”1 Interventions should focus on optimizing the individual’s function. Physical therapy interventions fall into the following 9 categories1:

• Patient or client instruction (used with every patient and client)

• Airway clearance techniques • Assistive technology • Biophysical agents • Functional training in self-care and domestic, work,

community, social, and civic life • Integumentary repair and protection techniques • Manual therapy techniques • Motor function training • Therapeutic exercise

Outcomes As physical therapy interventions are initiated, the

patient’s progress toward the established goals is monitored through the collection of outcomes data. Outcomes data are gathered using tests and observations related to the patient’s response to physical therapy interventions. The data (outcomes) are then compared to the initial findings to determine what progress, if any, has occurred. Since outcomes data include a variety of types of data some outcomes data should be noted at every patient encoun- ter. Observations of the patient’s functional status, motor control, and more should be made and documented. Other tests are more time consuming and complex and should be scheduled at specific times that correlate with established goals, legal requirements (state practice acts), facility policy, and/or third-party payer mandates. At various times within an episode of care, re-examination may occur to formally document the patient’s status and progress, or lack thereof. Based on the findings from the re-examination, the physi- cal therapist may revise the plan of care.

Discharge/Discontinuation of Services In the plan of care, established as a result of the initial

examination and evaluation, the physical therapist will address discharge plans. Depending on several variables (eg, the care setting, the established goals, the patient’s progress, the patient’s prognosis), the plan may include transfer to another therapy service in another care setting (eg, acute rehab, skilled nursing, outpatient, home health). When established goals are met, discharge from an episode of care occurs. Additionally, discontinuation of physi- cal therapy services may occur without established goals being achieved. When this happens, the physical therapist should document why the established goals were not met.3 Upon discharge or discontinuation, the patient/client may

be given a home exercise program or may be placed on a maintenance therapy program to maintain maximum functional capabilities in the absence of skilled therapeutic intervention. The establishment of a home exercise pro- gram, whether during the episode of physical therapy care or at the conclusion of services, should be a part of the plan of care established by the physical therapist.

PHYSICAL THERAPIST AND PHYSICAL THERAPIST ASSISTANT ROLES

The APTA Direction and Supervision of the Physical Therapist Assistant4 clearly outlines the roles that the physical therapist and physical therapist assistant perform within the Patient/Client Management Model. The physical therapist is the recognized professional who establishes, guides, and directs all aspects of the provision of physical therapy services. It is the responsibility of the physical ther- apist to interpret referrals; perform the initial examination and evaluation; establish the physical therapy diagnosis, prognosis, and plan of care (including goals and discharge plan); and determine which interventions require the clini- cal decision-making skill of a physical therapist and which interventions can be provided by a physical therapist assis- tant. In addition, the physical therapist is responsible for the re-examination of the patient and the revision of the plan of care when indicated. The physical therapist is also directly responsible for ensuring appropriate documentation for all physical therapy services.4

As a physical therapist assistant, your role in patient care activities falls within the intervention and outcomes portions of the Patient/Client Management Model. You will implement selected interventions of the plan of care as directed by the physical therapist. You may provide spe- cific interventions from any of the 9 intervention categories listed previously. You must be able to utilize sound clinical reasoning to determine the patient’s readiness to engage in the selected interventions and the patient’s response(s) to the intervention(s) being providing. You will need to deter- mine when to consult with the physical therapist about the patient’s status and progress or lack thereof. Throughout the provision of interventions, you will also need to perform appropriate tests to collect outcomes data to determine the patient’s appropriateness to engage in selected interven- tions and to provide information useful in determining the patient’s progress toward the goals established by the physi- cal therapist. As a physical therapist assistant, you will need to modify details of the physical therapist’s treatment pro- gram to facilitate patient progression within the established plan of care or to ensure the patient’s safety and comfort while engaged in the interventions being provided.5

Whether interventions are provided by the physical therapist directly or by a physical therapist assistant, the physical therapist remains responsible for all aspects of the physical therapy services. As a physical therapist assis-

The Physical Therapy Episode of Care 15

tant, you will be responsible for only providing the patient care interventions directed to you by the patient’s physical therapist. You will share the responsibility with the physical therapist to ensure that you only provide patient care inter- ventions within your education and skill level and within legal parameters for the state in which you practice.6-8 It will also be your responsibility to clearly and accurately document all patient care activities that you provide.4,8

For the provision of physical therapy services to be efficient and effective, a positive working relationship must exist between the physical therapist and the physical therapist assistant. This type of relationship is character- ized by trust and mutual respect, as well as an appreciation for individual differences. A hallmark of a good working relationship is excellent communication.9,10

COORDINATION, COMMUNICATION, AND DOCUMENTATION

To ensure optimal outcomes from physical therapy ser- vices, it is imperative that appropriate coordination of ser- vices and communication related to those services occur. Both components can be facilitated through, and should (at a minimum) be outlined in, concise documentation. Collaboration of services includes working with a variety of health care providers and, most importantly, the patient and the patient’s family/support structure. Collaboration only occurs in the presence of rich communication. To be able to function within the health care delivery system, you will need to effectively communicate with other members of the health care delivery team. Effective communication includes appropriate verbal and nonverbal communication, as well as accurate documentation. Accurate and effective documentation will provide the foundation upon which all clinical activity occurs. Documentation of the patient’s epi- sode of physical therapy care occurs initially with the initial examination/evaluation and throughout the episode of care with interim notes including treatment session notes and re-examination/re-evaluation notes. The final documenta- tion is a discharge summary that provides a summary of the entire episode of care, a description of the patient’s status at the time of discharge, and information regarding any additional recommendations for follow-up care (Table 2-2).

Now that we have looked at the Patient/Client Management Model and we have a clear picture of how a patient transitions through an episode of care, let’s take a closer look at how documentation plays a part within the provision of physical therapy services.

REFERENCES 1. American Physical Therapy Association. Guide to Physical

Therapist Practice 3.0. APTA Website. http://guidetoptprac- tice.apta.org/content/1/SEC2.body. Updated August 1, 2014. Accessed October 24, 2016.

2. American Physical Therapy Association. FAQ: direct access at the state level. APTA Website. http://www.apta.org/ StateIssues/DirectAccess/FAQs/. Accessed July 7, 2017.

3. American Physical Therapy Association. Defensible docu- mentation: components of documentation within the patient/ client management model. APTA Website. http://www.apta. org/Documentation/DefensibleDocumentation/. Accessed January 17, 2017.

4. American Physical Therapy Association. Guidelines: Physical Therapy Documentation of Patient/Client Management. BOD G 03-05-16-41. http://www.apta.org/ uploadedFiles/APTAorg/About_Us/Policies/Practice/ DocumentationPatientClientManagement.pdf. Updated December 14, 2009. Accessed July 7, 2017.

5. American Physical Therapy Association. Direction and supervision of the physical therapist assistant. HOD P06- 05-18-26. http://www.apta.org/uploadedFiles/APTAorg/ P r a c t i c e _ a n d _ P a t i e nt _ C a r e / Move m e nt _ Sy s t e m / MovementSystemSummit_Prereadings.pdf Accessed July 7, 2017.

6. American Physical Therapy Association. A Normative Model of Physical Therapist Assistant Education. Alexandria, VA: American Physical Therapy Association; 2007.

7. American Physical Therapy Association. Minimum required skills of physical therapist assistant graduates at entry- level. BOD G11-08-09-18. https://www.apta.org/upload- edFiles/APTAorg/About_Us/Policies/BOD/Education/ MinReqSkillsPTGrad.pdf. Accessed January 14, 2017.

8. American Physical Therapy Association. Standards of ethical conduct for the physical therapist assistant. APTA Website. https://www.apta.org/uploadedFiles/APTAorg/About_Us/ Policies/Ethics/CodeofEthics.pdf. Accessed January 14, 2017.

9. Holcomb S. Recipe for effective teamwork: why some PT/ PTA pairings thrive, to patient’s ultimate benefit. PT Magazine. February 2009. http://www.apta.org/PTinMotion/2009/2/. Accessed January 15, 2017.

10. American Physical Therapy Association. PT/PTA teamwork: models in delivering patient care. APTA Website. http:// www.apta.org/SupervisionTeamwork/Models/. Accessed January 15, 2017.

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Table 2-2 Episode of Care Documentation

Documentation Notes

Written By When Includes Purpose

Initial Physical therapist

At the initiation of an episode of care prior to provision of any interventions

• A description of the patient status

• Findings from the examination

• The physical therapist’s evaluation

• The physical therapist’s plan of care

Provides data needed for the physical therapist to determine the plan of care

Interim̶ Treatment Session

Physical therapist or physical therapist assistant who provided the interventions

At every patient care encounter

Interim̶ Re-examination/ Re-evaluation

Physical therapist

Discharge Summary

Physical therapist

At the end of an episode of care

The Physical Therapy Episode of Care 17

REVIEW QUESTIONS 1. Create a concept map that depicts an episode of physical therapy care from the point of entry through discharge.

2. Describe how patients access physical therapy care. Provide 3 examples of how a patient might gain access to a physical therapist.

3. Define and describe the 5 elements of the Patient/Client Management Model.

4. Next to each component of the Patient/Client Management Model, indicate whether the physical therapist (indicate with PT), the physical therapist assistant (indicate with PTA), or both participate(s) in that process.

Examination Evaluation Diagnosis Prognosis Intervention Outcomes

5. Describe the types of decisions made by the physical therapist during the evaluation process.

6. List the essential components of a plan of care.

7. What is the importance of outcomes measures in patient/client management?

8. Describe the role of the physical therapist assistant in the physical therapy process. List the responsibilities of the physical therapist assistant within that role.

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APPLICATION EXERCISES I. Reference the physical therapy practice act for your state of residence for language regarding direct access. Are there

any restrictions or provisions related to direct access in the practice act? If so, what are they?

II. Reference the physical therapy practice act for your state or residence for language regarding documentation. What are the responsibilities of the physical therapist assistant regarding documentation? What, if any, are the restric- tions placed upon the physical therapist assistant regarding documentation? Compare your state practice act with a practice act from a different state. What are the similarities? What are the differences? Discuss how these differing requirements can impact the operation of physical therapy in a variety of settings.

III. Interview a friend or family member who has received physical therapy services. Ask him or her to describe how he or she entered the physical therapy care system. Ask him or her to describe the process as he or she remembers it. Compare the information that you receive with the experiences reported by other interviews performed by your classmates.

Mia L. Erickson, PT, EdD, CHT, ATC

Erickson ML, McKnight R. Documentation Basics for the Physical Therapist Assistant, Third Edition (pp. 19-28)

Reasons for Documenting

Chapter 3

After reading this chapter, the reader will be able to do the following: 1. List the major reasons for documenting. 2. Identify the types of patient data found in a medical

record. 3. Explain how clinical decision making can be articu-

lated in a medical record. 4. Explain the role of the physical therapist assistant in

the clinical decision-making process. 5. Describe the reasonable and necessary criteria. 6. Differentiate between skilled care and maintenance

therapy. 7. Explain how to document the patient’s response to

treatment. Imagine that you are working as a physical therapist

assistant in a small outpatient clinic. For the last 6 weeks, you and your supervising physical therapist have been working with a 35-year-old man who was recently involved in a motor vehicle accident. He sustained a concussion and multiple fractures including the left femur and radius.

Initially, he was unable to bear weight through either extremity and required a wheelchair as his primary mode of mobility. He had significant loss in range of motion and was unable to perform self-care, home/community mobil- ity, and work activities. He has been making excellent progress and is now able to walk using one crutch and has resumed most of his normal activities of daily living. The physical therapist with whom you are working receives a call from the patient’s insurance company stating that they are going to deny payment for physical therapy services. To have additional therapy services approved, the clinic must submit adequate documentation showing that further skilled services are medically necessary.

LEGAL AND ETHICAL RESPONSIBILITY As a physical therapist assistant, documentation will be

one of the most important things you do. In health care, documentation provides a legal record of care, facilitates communication among health care providers, and serves as a source of information for clinical research.1 Both state and federal laws mandate recording health care provided to an individual. Facilities and organizations providing com-

CHAPTER OBJECTIVES

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ponents of the Patient/Client Management Model discussed in Chapter 2 have policies pertaining to documentation.

Medical records are legal documents, and any entry you make into the medical record becomes part of that legal document; therefore, it is important that your docu- mentation is accurate, legible, and completely depicts the patient’s condition and intervention provided. Be aware that a patient’s medical records can be subpoenaed and used as evidence in a variety of legal matters. These include motor vehicle accidents, workers’ compensation or dis- ability claims, and malpractice suits brought against you or other health care providers. In malpractice lawsuits, documentation is the clinician’s first line of defense. Good documentation can stop a lawsuit in its tracks, and poor documentation can be “powerful evidence in support of a suit, even when the accusations are frivolous.”2 Consider the following as a rule of thumb: “If it isn’t documented, it didn’t happen.”

In addition to legal obligations, maintaining accurate, timely, well-written patient records is considered one of your ethical duties as a physical therapist assistant. The Standards of Ethical Conduct for the Physical Therapist Assistant states, “Physical therapist assistants shall ensure that documentation for their interventions accurately reflects the nature and extent of the services provided.”3

REIMBURSEMENT Reimbursement means “to pay back” for a service that

has been provided.4 In health care, either the patient or a third party (eg, an insurance company, government agency such as Medicare) pays for services. Medicare and Medicaid began requiring documentation for reimbursement in phys- ical therapy in the 1960s.1 Soon after that, Medicare began a restructuring process and started requiring rehabilitation facilities to not only maintain documentation, but also to submit the records for review by Medicare auditors. The purpose of these reviews was to determine whether physi- cal therapy services provided to Medicare beneficiaries met requirements for reimbursement. As the US health care delivery system has evolved over the last decades, third- party reimbursement from all payers has become another reason for documenting patient care. Reimbursement from third-party payers can be dependent upon documenta- tion in that, to receive payment, the documentation must support the services provided. Consider the patient case discussed earlier in this chapter. Continuation of his physi- cal therapy benefits is based largely on how well the clini- cians have documented his improvement and the need for ongoing services. Communication with third-party payers through appropriate documentation has been called the “key to securing reimbursement.”5

RECORD PATIENT DATA One of the primary reasons for documenting physical

therapy services is to maintain a record of patient data. These data should reflect the entire episode of patient care, from start to finish, beginning with an initial examina- tion performed by the physical therapist and ending with a discharge summary. During the initial examination, the physical therapist collects and records data pertaining to the patient’s current condition. These include both subjec- tive and objective information. The history-taking portion of the initial examination provides the physical therapist with subjective information. It includes what the patient, family member, or caregiver says pertaining to the patient’s condition. History of the current condition, mechanism of injury, date of onset, and history of a similar problem are all examples of subjective information gathered during the initial examination. Other subjective information collected at this point should include a thorough medical history, a review of the patient’s living situation, chief complaints (including his or her activity limitations and restrictions in his or her ability to participate in normal life roles or tasks), and his or her goals for physical therapy. Information relat- ed to the patient’s functional status can be gleaned through direct questioning by the physical therapist or through the use of patient self-report measures. Self-report measures are questionnaires that ask the patient to rate his or her abil- ity to perform functional tasks. Data from these question- naires provide the physical therapist and physical therapist assistant with information about patient functioning from the patient’s perspective.

In addition to subjective information, documented data should include objective information or results from the systems review and objective tests and measurements. Examples of these types of objective data include mea- surements of range of motion, strength, sensation, girth, balance, and functional status (eg, walking, transferring, performing activities such as self-care and home manage- ment). While data from self-report measures of function are often considered part of the subjective information, data from observable patient performance of a functional task are considered objective information. Objective data pro- vide additional information to help identify and measure the extent of the patient’s impairments, activity limitations, and participation restrictions. Self-report measures, obser- vation of functional performance, and performance-based measures can be used together to provide information about the patient’s functional status.

A record of the patient’s functional status provides particularly valuable information regarding the effects of the disease or injury on the patient’s normal activities and lifestyle. Furthermore, individuals reviewing medical records deem the patient’s functional status as being more meaningful than documentation of impairments alone.

Reasons for Documenting 21

Although impairment data are necessary, documenting function, including activity limitations and participation restrictions, provides reviewers with specific contextual information regarding the impact of injury on the patient’s lifestyle.

Both subjective and objective data provide physical therapists and physical therapist assistants with baseline measurements with which future measurements can be compared.6 Information taken from the patient, as well as objective measurements, are not only documented during the initial examination, but also during subsequent physical therapy sessions. In subsequent sessions, data are recorded in the form of treatment or interim notes, progress reports, or, in the case of discharge from physical therapy services, a discharge summary. In any event, any data collected after the initial examination should be recorded. It will be compared with that found in the initial examination. These comparisons allow the medical record to reflect both sub- jective (patient comments) and objective (data from tests/ measurements) changes in the patient’s status.

Records of patient data are important to others involved in the patient’s care. Health care providers such as physi- cians, nurses, occupational and speech therapists, and case managers, among others, are often interested in a patient’s status and therefore might examine physical therapy docu- mentation. Physicians might be interested in how far a patient can walk prior to deciding on discharge from the hospital. Nurses might be interested in a patient’s ability to transfer out of the bed, whereas case managers might want to examine equipment needs or return-to-work sta- tus; therefore, documentation serves as a useful tool for facilitating communication across disciplines. In addition to other health care providers, third-party payers are inter- ested in records of patient data.

Accurate records of patient data also aid in our ability to analyze and study patient outcomes. Outcomes are defined as the end result of patient/client management.7 Collection of outcomes data is an important area of physical therapy practice, and it is necessary to support and validate the physical therapy services provided. Outcomes data are also necessary to support evidence-based practice. For example, analysis of patient outcomes can allow us to determine the effectiveness of physical therapy interventions. Use of standard terms, such as those provided by the International Classification of Functioning, Disability and Health in our data collection can also support outcomes data collection.8

RECORD PATIENT CARE Your documentation will also serve as a record of the

care you provided to your patients. Interventions are divided into 3 categories. The first is procedural interven- tions. These are considered direct interventions and include those related to direct patient care, such as modalities, physical agents (eg, ice, heat), massage, stretching exercises, strengthening exercises, gait training, and transfer train-

ing. The second category is coordination and communica- tion. This is more indirect but is still an important aspect of patient care. Examples include communicating with family members, other health care providers, or any other individual involved in the care of the patient. Phone calls, relevant conversations regarding the patient, and collabora- tion with other providers, including the physical therapist, must also be documented as part of the patient’s record. The third category is patient/client-related instruction. This category includes teaching that was provided to the patient, family, or caregiver as well as his or her understanding or response to the teaching. Both physical therapists and physical therapist assistants are responsible for accurately recording services provided in each of these 3 categories.

Documented interventions serve to support treatment that was billed for a given date of service. Third-party pay- ers may perform a documentation audit to assure that the treatment provided and billed is supported by the clini- cian’s documentation. Inaccurate or incomplete documen- tation that does not support daily charges may be construed as fraud or abuse and must be avoided.

Accurately recording patient care is also necessary where electronic billing and documentation software are integrated. In these situations, the patient’s charges are generated based on the interventions that the therapist provided and documented in the day’s note. Incomplete or inaccurate documentation may generate too many or too few charges to the patient’s account. Additionally, a patient may be charged for a service not provided. Again, these inconsistencies can prompt an audit, which can result in fines, repayment, or accusations of abuse or fraud, so it is very important that the record accurately reflects all aspects of the care provided to the patient.

Another reason for documenting patient care is to keep a record for other therapists in the event of your absence. In the event of an emergency where a physical therapy pro- vider is unable to come to work, another physical therapist or physical therapist assistant should be able to pick up the record and provide the appropriate patient care. This main- tains consistency of care across providers.

In addition to specific patient care provided, it is impor- tant to document the patient’s response to treatment. This can be done in a variety of ways. Thinking in terms of dis- ablement, response to treatment should provide informa- tion as to how the interventions are positively or negatively influencing the patient’s impairments, activity limitations, or participation restrictions. For example, a physical thera- pist could record the following:

Dynamic balance training and lower-extremity strength- ening exercises have allowed the patient to improve balance as measured by the Berg Balance Scale and the patient is now at less risk for falls.

In this example, the physical therapist documented the patient’s overall response to treatment in terms of impair- ments (improved balance) and function (less risk of falls). Consider the following example written by a physical thera- pist assistant:

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Upon arrival, the patient was complaining of 6/10 pain in the right buttock and leg and was having difficulty sit- ting. Following modalities and extension exercises, the pain decreased to 3/10 and was no longer radiating down the patient’s leg.

When the response to treatment is documented in this manner, the note reflects how the interventions brought about a change in the patient’s status, and it supports treat- ment effectiveness. Being specific in the patient’s response can show a third-party payer how the patient is improving and how the treatment is influencing impairments and function.

Documenting response to treatment can serve as a record of unexpected events that may have taken place and your response. For example, when a patient returns for a therapy visit and has increased soreness after performing his home exercise program, the physical therapist assistant can make adjustments within the plan of care to lower the exercise intensity. Patient complaints should be document- ed, and the therapist’s actions in response to the patient’s complaints should also be documented. The therapist’s response to an adverse event may not always be directed toward the patient. Consider the following example:

A physical therapist goes to see a patient 4 weeks post total knee arthroplasty for a re-evaluation in the patient’s home. The patient is complaining of severe knee pain, swell- ing, nausea, redness, elevated skin temperature, and white drainage from the incision. Upon observation, the physical therapist believes that the patient has an infection and calls the physician.

The physical therapist should document the events that took place, the observations, any assessments, and his or her action. Documenting response to treatment and your actions, when appropriate, helps to show patient manage- ment and clinical decision making in response to positive or negative events.

PROVIDE PROOF THAT CARE IS REASONABLE AND NECESSARY

Our documentation must provide evidence that physical therapy services are reasonable and necessary. The Centers for Medicare & Medicaid Services has set forth the follow- ing criteria that need to be met for services to be considered reasonable and necessary9:

• “The services shall be considered under accepted stan- dards of medical practice to be a specific and effective treatment for the patient’s condition.”

• “The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effec- tively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist.”

• “While a beneficiary’s particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary’s diagnosis or prognosis can- not be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treated the illness or injury, or whether the services can be carried out by nonskilled personnel.”

• “The amount, frequency, and duration of the services must be reasonable under accepted standards of prac- tice. The contractor shall consult local professionals or the state or national therapy associations in the devel- opment of any utilization guidelines.”

Documentation to justify reasonable and necessary services includes initial documentation that describes the patient’s pathology, impairments, activity limitations, and participation restrictions. The documentation includes a description of how the impairments have led to limitations in a patient’s activity level or restrictions in a patient’s ability to participate in normal life roles or tasks. Documentation outlines a specific plan of care or interventions aimed at addressing these limitations, and it includes ongoing reas- sessments to show changes in status. The documentation must convey how the interventions are influencing the patient’s condition. Furthermore, the documentation must show how the interventions provided required the unique and complex skills or decision making of a therapist. Finally, the frequency and duration of services should be consistent with what would be considered appropriate for the case.

In most cases, the physical therapist provides evidence that services are reasonable and necessary in the initial documentation. The physical therapist assistant, however, plays an important role in recognizing when the interven- tion is no longer reasonable and necessary. For example, intervention may no longer be reasonable and necessary if any of the following occurs: (1) the patient has met all of the goals that have been established by the physical therapist; (2) the patient is no longer benefiting from the interven- tion; or (3) the services can be carried out through home exercise instructions or by untrained personnel. Treatment might also exceed the reasonable and necessary criteria if a patient, family member, or caregiver has unrealistic expectations for recovery.10 Documentation showing objec- tive, comparative data can help to provide evidence that a patient is progressing toward the goals stated in the plan of care. Documentation can then further support the need for subsequent or continued interventions under the reason- able and necessary criteria, or it can provide justification for discontinuing physical therapy services.

PROVIDE PROOF OF SKILLED CARE Medicare has provided definitions for skilled care and

documentation criteria.11 When determining if a service is skilled, it is always important to first consider the service

Reasons for Documenting 23

being provided and whether it reaches a level of complex- ity that it must be carried out by a therapist or under the supervision of a therapist for both safety and effectiveness. As stated in the previous section, the patient’s medical con- dition is a valid factor in determining if skilled services are needed; however, it is never the only factor.

There may be times when an unskilled service could be considered a skilled service. This is the case when a patient’s medical condition, comorbidities, or complicating factors are such that the service should be provided or supervised by a therapist for safety and effectiveness. Consider passive exercises for example. In some cases, passive exercise would be considered unskilled; however, if a patient presents with a humeral fracture and requires passive elbow exer- cises, then, due to the condition, the intervention would be considered skilled. Unskilled services are often known as maintenance therapy. Maintenance therapy services can be provided by a nonlicensed individual, such as a family member or caregiver who has had some training from a skilled professional, or by the patient through independent home exercises. Medicare and other third-party payers do not reimburse for maintenance services.12

Documentation in all cases must be thorough enough to show a reviewer that the services were skilled. The Medicare Benefit Policy Manual outlined documentation require- ments to support skilled care determinations.11 According to these guidelines, there should be sufficient documenta- tion to help a reviewer determine the following: (1) the service requires the skills of a therapist to be considered safe and effective; (2) the service is reasonable and necessary and consistent with the nature and severity of the illness or injury, the patient’s medical needs, and accepted standards of practice; and (3) the service is appropriate in terms of duration and quantity and is designed to meet a document- ed therapeutic goal. In addition, the medical record should provide thorough documentation of the history and physi- cal examination pertinent to the patient’s care (including response to treatment from previously administered skilled interventions), the skilled services provided to the patient, the response to the skilled services provided during the current visit, the plan for future care based on the rationale of prior results, a rationale that explains the need for skilled service in light of the condition, the complexity of the services provided, and any other pertinent patient charac- teristics that would support the need for skilled services.11

These documentation requirements state that the patient’s record should be accurate and specific in docu- menting the patient’s response to skilled care, avoiding vague and subjective descriptions such as “tolerated treat- ment well,” and “continue with plan of care” since these phrases do not adequately describe the patient’s response in objective terms.11 Rather, requirements state that objective measurements of physical outcomes and/or a clear descrip- tion of the patient’s response(s) that occurs as a result of the skilled service should be provided. This allows for all con- cerned to be able to follow the results of the skilled services provided.11

DEMONSTRATE THE CLINICAL DECISION-MAKING PROCESS

From initial examination to discharge, physical therapy documentation should provide a picture of the clinician’s decision-making processes and clinical judgment.2,10,12 Documentation that demonstrates clinical decision mak- ing also improves the provider’s credibility with third- party payers.5 An individual who does not know the patient should be able to read the physical therapy records and identify a logical, stepwise progression from initial exami- nation to discharge. Lewis2 indicated, “documentation of all elements of the Patient/Client Management Model… should harmonize.” Documentation should reflect logical decisions and sound judgment by showing direct links between subjective remarks; objective measures of impair- ments activity limitation and participation restriction; therapy goals; skilled interventions; responses to the skilled interventions in objective, measurable terms; changes in interventions, when appropriate; and a rationale for dis- charge.

Both the physical therapist and physical therapist assis- tant have specific roles in making sure that this occurs, as follows:

• Data collected during the initial examination should be reflected in the plan of care. For example, goals written by the physical therapist should reflect impairments (ie, decreased range of motion, decreased strength), activ- ity limitations (ie, difficulty transferring, decreased independence with gait), and participation restrictions (ie, unable to work) identified during the initial exami- nation (physical therapist role).

• The plan of care should include physical therapy interventions that are aimed at reducing the identified impairments, activity limitations, and participation restrictions (physical therapist role).

• Changes in patient status should prompt changes in the plan of care (physical therapist and physical thera- pist assistant role to recognize and record changes in patient status, physical therapist assistant role to com- municate changes to the physical therapist, and physi- cal therapist role to adjust the plan of care based on patient changes).

The physical therapist assistant can further contribute to the decision-making process by collecting pertinent subjec- tive and objective patient data in visits following the initial examination, before and after providing interventions. Subjective data often gathered and recorded by a physical therapist assistant include the following:

• Asking the patient about his or her response to a previ- ous treatment.

• Inquiring about compliance with a home exercise program.

• Asking the patient whether the treatment has improved his or her function.

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When asking a patient whether the treatment has improved his or her function, it is important to refer back to the initial documentation to see what limitations the patient had when he or she started the episode of care. That way, additional inquiries can be directed at specific activity limitations and participation restrictions.

Prior to collecting objective data through tests and mea- surements, it is important to see what measurements were taken during the initial evaluation. These initial measure- ments serve as a baseline for determining future measure- ments that are needed and for which future measurements should be compared. In addition, it is important to try to speak with the physical therapist about the patient prior to the treatment session. At that time, one should ask whether additional tests and measurements are needed. Objective data often gathered by a physical therapist assistant include but are not limited to the following:

• Goniometric measurements • Manual muscle testing • Functional status (bed mobility, transfers, gait)

The physical therapist assistant records subjective patient comments and results of relevant tests and mea- surements in interim notes or daily notes. These notes help to tell the story of the patient and can lend support to patient improvement. Subjective and objective findings that warrant a re-evaluation, changes in the plan of care, or discharge should also be provided in the documentation by the physical therapist assistant and communicated to the physical therapist.

When there is consistency between the initial examina- tion and subsequent notes, the clinical decision-making process is more apparent. Ongoing documentation of subjective remarks and objective findings tells the story of the patient’s response to therapy. In addition, consistency between initial and subsequent documentation makes it easier for the clinician(s) to identify progress or lack there- of. This also allows the physical therapist to easily update goals and interventions as needed.

REFERENCES 1. Inaba M, Jones SL. Medical documentation for third-party

payers. Phys Ther. 1977;57(7):791-794. 2. Lewis DK. Do the write thing: document everything. PT

Magazine. 2002;10(7):30-34. 3. American Physical Therapy Association House of

Delegates. Standards of Ethical Conduct for the Physical Therapist Assistant. HOD S06-09-20-18 [Amended HOD S06-00-13-24; HOD 06-91-06-07; Initial HOD 06-82- 04-08] [Standard]. APTA Website. http://www.apta.org/ uploadedFi les/APTAorg/About _Us/Pol icies/Ethics/ StandardsEthicalConductPTA.pdf. Accessed July 8, 2017.

4. Definition of reimbursement. Dictionary.com Website. http:// www.dictionary.com/browse/reimbursement. Accessed July 8, 2017.

5. Baeten AM. Documentation: the reviewer perspective. Top Geriatr Rehabil. 1997;13(1):14-22.

6. Hebert LA. Basics of Medicare documentation for phys- ical therapy. Clinical Management in Physical Therapy. 1981;1(3):13-14.

7. American Physical Therapy Association. Guide to Physical Therapist Practice 3.0. APTA Website. http://guidetoptprac- tice.apta.org/content/1/SEC2.body. Updated August 1, 2014. Accessed October 24, 2016.

8. Goode N. The reliable resource: physical therapy documen- tation. PT Magazine. 1999;7(9):30-31.

9. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual. Chapter 15-Covered Medical and Other Health Services. CMS.gov website. https://www. cms.gov/Regulations-and-Guidance/Guidance/Manuals/ Downloads/bp102c15.pdf. Updated July 11, 2017. Accessed July 8, 2017.

10. Redgate N, Foto M. Pay by the rules: avoid Medicare audits and reduce payment denials with a sound strategy and prop- er documentation. Physical Therapy Products. 2003;October/ November:28-30.

11. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual. Chapter 8-Coverage of Extended Care (SNF) Services Under Hospital Insurance. CMS.gov website. https:// w w w.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/downloads/bp102c08.pdf. Updated October 13, 2016. Accessed July 8, 2017.

12. Moorhead JF, Clifford J. Determining medical necessity of outpatient physical therapy services. Am J Med Qual. 1992;7(3):81-84.

Reasons for Documenting 25

REVIEW QUESTIONS

1. List reasons for documenting.

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.

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

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

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

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

7. List some examples of how a physical therapist or physical therapist assistant should document a patient’s response to treatment.

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

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

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

Chapter 326

APPLICATION EXERCISES Read through the following initial examination/evaluation performed and documented by the physical therapist, and answer the questions that follow.

Date: March 15, 2017 Patient: David White Pr: 27 y.o. s/p (L) wrist and ankle fx; Referral: Begin gentle wrist and ankle AROM and PROM; May begin using

crutches with platform for (L) UE. PWB 50% on (L) LE. S: HPI: 4 weeks s/p fall (~25’) from a logging truck landing on his (L) side (2/1/17). Pt. sustained fx of the (L) distal

radius and ulna and (L) distal tibia and fibula. Pt. underwent ORIF for the wrist and ankle immediately after the injury. He was placed in a short-arm cast for the UE and short-leg cast for the LE. He was NWB on the (L) LE initially and has been unable to use crutches due to not being allowed to bear weight on the affected UE. He was hospitalized for 5 days following the injury. While hospitalized, he received PT to learn how to negotiate his w/c and perform transfers. Both casts were removed yesterday and his ankle was placed in a removable splint. He reports taking ibuprofen PRN for pain. C/C: Pain and stiffness in (L) UE and LE with decreased functional use of both. Doesn’t like using w/c for mobil- ity. Unable to work. Requiring assist with self-care activities and home management. Living situation: Right-hand dominant; Lives with wife and 2 small children in single-level home with 2 steps @ entrance and hand rail on the (R). Pt. is unable to drive and is relying on his wife and mother for transportation. Work history: Prior to injury, pt. was employed as a construction worker. He has been off work since the injury. PMH/family history: Pt. reports being in good general health. Prior to injury pt. was independent in all func- tional activities in and around the home. No significant PMH or history of fracture. Family history is (+) for OA. Social/health habits: Reports being a nonsmoker and nondrinker. Self-report of function: DASH score: 85%; FAAM score: 9%; Global rating of function: 9%. Pt.’s goals: Return to previous level of function and RTW ASAP. Learn to ambulate with crutches.

O: Systems Review: Cardiovascular system: HR: 80 bpm, RR: 12, BP 125/75; Integumentary system: Healed scars on the volar surface of the (L) wrist and lateral surface of the (L) lower leg. Scars are pink, slightly raised (< 2mm), and slightly adhered to the underlying tissue. Neuromuscular system: Impaired, see below; Musculoskeletal system: Impaired, see below. Communication and cognition: No impairments identified, able to communicate without difficulty. Tests and Measures:

AROM PROM (L) wrist: Flexion 0° 25°

Extension 10° 15° UD 10° 15° RD 15° 15° Supination 30° 35° Pronation 40° 45°

(L) hand: Patient can perform a full fist but it is difficult due to edema. Thumb IP, MCP, and CMC AROM is WNL

(L) knee: 0-100° 0-110° (L) ankle: DF -10° -5°

PF 20° 25° Inversion 5° 5° Eversion 0° 5°

Reasons for Documenting 27

AROM: (R) UE and LE WNL; (L) shoulder, elbow, and hip WNL. Strength: (R) UE and LE 5/5; grip strength (#2 handle setting) 110#; (L) shoulder and hip 4/5; (L) elbow, wrist, knee, and ankle deferred 2° to acuity. Girth: wrist figure 8 (R): 36 cm (L): 37.2 cm; ankle figure 8 (R): 42 cm (L): 44.1 cm. Sensation: Diminished light touch at the (L) wrist and ankle incisions Circulation: 2+ at radial and dorsal pedal arteries on the (L). Special Tests: N/A @ this time 2° to acuity. Gait: Ambulates 50’ PWB 50% (L) LE using crutches with (L) UE platform using step to gait pattern with CGAx1 for sequencing and balance. Transfers: (I) bed to and from chair, chair to and from toilet, sit to and from stand; all PWB on (L) LE. Bed Mobility: (I) all areas. Tx and HEP: Ther Ex x 30 minutes including AROM and PROM for (L) wrist for flexion, extension, pronation, and supination and for (L) ankle DF and PF, used opposite foot for self PROM of ankle; performed AROM for all digits and thumb; initiated compression glove for edema to be worn at night; instructed pt. in elevation and com- pression wrapping for ankle and wrist; Gait training x 15 minutes including instruction in use of crutches. Pt. performed all ex. x 20 reps (I) and verbalized understanding of all precautions.

A: 27 y.o. RHD male 4 wks s/p fall where he sustained fx to the (L) wrist and ankle. Now decreased AROM, PROM, strength, and weightbearing restrictions are causing inability to ambulate, perform self-care, drive, or perform home management tasks without assistance. He is also unable to work @ this time. Pt. demonstrates excellent motivation and good potential for full recovery. No comorbidities identified that could affect outcome at this time.

Problem List: 1. Decreased AROM and PROM of the (L) hand, wrist, forearm, knee, and ankle 2. Edema in the (L) hand and ankle limiting ROM 3. Decreased strength in the (L) UE and LE 4. Limited (I) in mobility including ambulation 5. Unable to ascend and descend stairs 6. Decreased (I) with self-care 7. Decreased (I) with home management 8. Unable to drive 9. Unable to work Anticipated Goals and Expected Outcomes: At the end of 4 weeks, pt. will: 1. Increase AROM 20-25° for the wrist, forearm, knee, and ankle to improve use of UE and LE during functional activities. 2. Decrease edema by 0.5 cm for the wrist and ankle to improve ROM. 3. Perform a full fist without limitations. 4. Ambulate 200’ with crutches with (L) UE platform PWB 50% on (L) LE independently. 5. Ascend and descend stairs with supervision and assistive device. 6. Perform all self-care independently. 7. Improve his score on the FAAM 8-16%. 8. Improve his DASH score 15%. At the end of 16 weeks (time of d/c), pt. will: 1. Achieve the following AROM: wrist extension 70°, wrist flexion 80°, supination 75°, pronation 75°,

knee 0-150°, ankle DF 10°, and ankle PF 50° to allow use during basic care, home tasks, and work activities.

2. Increase strength in the (L) wrist, knee, and ankle to 4/5 to allow normal function for RTW. 3. Achieve grip strength to 80% of (R) to allow use during basic care, home tasks, and work activities. 4. Ambulate independently on all surfaces without an assistive device. 5. Ascend and descend a flight of stairs independently without an assistive device. 6. Demonstrate (I) self-care. 7. Demonstrate (I) in home management tasks. 8. Drive without restrictions. 9. RTW @ previous level of employment.

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P: See pt. 3x/wk for next 3-4 mos. to provide skilled services including instruction in safe, appropriate therapeutic exercise program and progression, use of assistive device and gait training as ordered, retraining in functional mobility to prepare for return to normal lifestyle and RTW. Will progress pt. as tolerated when appropriate and according to MD orders. Pt. is in agreement with the above stated plan.

John Smith, PT 1. List 5 of the patient’s impairments. 2. List 2 of the patient’s activity limitations and 2 of his participation restrictions. 3. In this example, how are the patient’s impairments creating activity limitations and participation

restriction? 4. List 5 pieces of subjective data found in the examination. 5. List 5 pieces of objective data found in the examination. 6. What other providers/individuals might be interested in looking at this patient’s note(s)? 7. What interventions were provided to the patient on this initial date of service? 8. How did the physical therapist describe the need for skilled care? 9. What information would you need to provide in a progress note for this patient to show medical

necessity and the need for further skilled care? 10. What examples can you see in this note that help in supporting the clinical decision-making process

used by this physical therapist?

Mia L. Erickson, PT, EdD, CHT, ATC

Erickson ML, McKnight R. Documentation Basics for the Physical Therapist Assistant, Third Edition (pp. 29-40)

Documentation Formats

Chapter 4

After reading this chapter, the reader will be able to do the following: 1. Describe each documentation format. 2. Examine the different physical therapy documentation

formats. 3. Explain the advantages and disadvantages of different

documentation formats. 4. Differentiate between information found in the S

(subjective), O (objective), A (assessment), and P (plan) portions of a SOAP note.

5. Identify the positive and negative aspects of using forms and templates.

6. Recognize the need for adapting clinical documenta- tion into a given format.

Documentation in physical therapy practice can take on a variety of formats depending on the type of patients being treated, practice setting, type of facility, state laws and practice acts, reimbursement requirements, and electronic medical record system being used. Historically, there have been several formats used in physical therapy practice, such as narrative reports, the problem-oriented medical record,

the SOAP note, and the functional outcomes report (FOR; Figure 4-1). While a brief discussion of each will be pro- vided, it is important to point out that, as the health care system transitions to electronic medical record keeping, one will have to be flexible in adapting to the templates provided by the software available at the site; therefore, it is important for new clinicians to have an overview of basic formats so that they can be able to adapt to a given computer interface.

NARRATIVE In narrative documentation, the clinician describes the

patient encounter in paragraph format.

Narrative Example #1 Date: 03/30/17 Patient: David White Pt. RTC reporting no adverse effects from treatment last

visit or from HEP. He stated that he feels as though his wrist and ankle are moving better and the edema in the hand has decreased. He reports improvement in his gait, ability to shower (I) using a plastic chair in the tub, and ability to

CHAPTER OBJECTIVES

KEY ABBREVIATIONS A | FOR | IDEA | IEP | IFSP | O | P | POMR | S | SOAP

Chapter 430

dress himself. AROM of the (L) wrist is as follows: flexion 30°, extension 30°, UD 15°, RD 20°, supination 45°, and pro- nation 60°; (L) knee: 0-135°; (L) ankle: DF 0°, PF 45°. Figure 8 wrist girth is 35.5 cm and ankle figure 8 girth is 43 cm on the (L). Pt. ambulated 1000’ (I) with crutches using (L) UE platform, PWB 50% on the (L) LE. Tx consisted of gentle AROM and PROM for 30’ to the (L) wrist and forearm in the directions of flexion, extension, supination, and prona- tion and to the (L) ankle for DF, PF, inversion, and eversion. Pt. also performed AROM for the fingers to improve the ability to make a tight fist. Pt. has made improvements in AROM and has decreased edema. His functional activity has also improved per subjective report. Will continue to have pt. perform his HEP and RTC on 4/5/17.

Bill Jones, PTA Several problems with the narrative record have been

reported. First, narrative notes can lack structure, making the writer prone to omit important details. In addition, there is a high degree of note-writing variability among clinicians.1 When medical notes lack structure and vary between clinicians, it becomes very difficult for others to read and locate necessary information. For example, it would be very time consuming for a physician or case man- ager to sort through a chart filled with unstructured nar- rative entries to locate information regarding the patient’s ability to transfer or ambulate. Furthermore, following the clinician’s problem-solving process can be difficult in nar- rative reports.2 Nevertheless, the use of narrative notes still occurs, and ways to improve readability with this format have been suggested. First, when using the narrative format, Quinn and Gordon1 recommended developing an outline of information to cover so that important details are not omitted. Also, using headings and subheadings can make information easier to find. Whether to use headings and which headings to use can often be left to the discretion of the individual clinician, but some facilities may have poli- cies as to which headings should and should not be used.

There are times when the narrative format is the most appropriate format to use. These include describing a

sequence of events, brief interactions with patients, con- versations with other health care providers, or any other situation that requires a detailed explanation and no other documentation formats are appropriate (see Narrative Example #2). These are also useful when documenting a cancellation, refusal to participate, or missed visit. In these instances, you can simply describe the situation and how it affects the patient in a brief paragraph or narrative note. Narrative notes are sometimes the easiest to use when you just need to describe the details of a situation and you are trying to paint a vivid description of what happened. The narrative format can be used in both paper and electronic medical records.

Narrative Example #2 Date: 04/01/17 Patient: David White Spoke with patient’s physician today regarding the

amount of weight bearing that he is allowed to perform when ambulating with the platform crutches. The physi- cian stated that his fracture sites on the radius and ulna are stable and healing well, and he can perform weight bearing as tolerated on the UE. Will have patient continue to use crutches with platform on the (L), allowing him to bear weight through the UE as instructed by the physician.

John Smith, PT

PROBLEM-ORIENTED MEDICAL RECORD The POMR was introduced by Lawrence Weed to

provide medical students with a structured documenta- tion format oriented around the patient’s problems.2 He believed that the narrative format was often confusing and unorganized, making it difficult to determine how the physician described and treated various patient problems.2 The POMR became a type of documentation used mainly by physicians. In the POMR, the first page of the medical record consisted of a patient problem list. This served as the table of contents for the remainder of the medical record.

Figure 4-1. Documentation formats.

Documentation Formats 31

Problem-Oriented Medical Record Example #1

Date: 03/15/2017 Patient: David White Problem 1: Decreased A/PROM left wrist Problem 2: Decreased A/PROM left ankle Problem 3: Decreased A/PROM left knee Problem 4: Decreased strength left wrist Problem 5: Decreased strength left ankle Problem 6: Decreased strength left knee Problem 7: Edema (L) hand and ankle Problem 8: Decreased ambulation Problem 9: Decreased self-care Problem 10: Decreased home management Problem 11: Unable to work Subsequent entries, or those that followed the initial

documentation, were organized according to each prob- lem.

The physician discussed the management of each prob- lem in separate entries using the following headings (see POMR Example #2):

• Subjective data: Symptomatic data provided by the patient

• Objective data: Results of the physical examination • Impression: The practitioner’s impression of the

patient and that particular problem • Treatment and therapy: Treatment or therapy provid-

ed for that particular problem on that day or session • Immediate plans (Plan): Treatment planned for that

particular problem

Problem-Oriented Medical Record Example #2

Date: 03/30/17 Patient: David White Problem #1: Decreased A/PROM of the (L) wrist Subjective data: Pt. reports no adverse effects from last

treatment; states that the wrist and hand are moving better and he can use them better during ADLs and functional activities around the house.

Objective data: AROM (L) wrist: flexion 30°, extension 30°, UD 15°, RD 20°, supination 45°, and pronation 60° taken before treatment.

Impression: Overall A/PROM improved from the initial examination. Also showed 10° improvement in wrist flex- ion, extension and supination following exercise during this session.

Treatment and therapy: 3 x 10 reps AROM and PROM for flexion, extension, supination, and pronation.

Plan: Have pt. continue with HEP and RTC in 2 days for progression of exercise.

Bill Jones, PTA

Using this format, the reader can identify the patient’s progress and care for each of the identified problems. Some authors reported on major advantages of the POMR at the time.3-8 Benefits of POMR included the following:

• Provided organization and structure to the medical information

• Included a comprehensive list of the patient’s problems • Discussed each of the patient’s problems separately • Provided a specific plan for managing each of the

patient’s problems (ie, treatment is problem-oriented) • Allowed a physician who is interested in a particular

problem to go directly to that aspect of the note, thus improving communication among care providers

• Provided a chronological sequence of interven- tions for a particular problem, better outlining the problem-solving process

Regardless of the benefits outlined at the time, after looking at POMR Example #2, limitations of the POMR become apparent. First, the POMR separates, or frag- ments, patients according to their problems, and this might pose a problem in complex cases if a provider does not see the “whole patient.”7

In POMR Examples #1 and #2, it is possible that a therapist working with the upper extremity might not be aware of the lower-extremity problems without reading separate chart entries. This could be very time consum- ing. In addition, for patients with multiple problems (as in POMR Example #2), the medical record will quickly become very long and complex, requiring an extraordi- nary amount of time for an individual who is managing multiple problems. If one therapist were managing this patient, there would be numerous chart entries required each visit; therefore, it has typically not been suitable for more complex rehabilitation patients.4

More contemporary versions of the POMR have emerged that are centered around patient problems. They often include the problem, associated goal, current sta- tus, treatment directed at the problem, and plans for future interventions. A more contemporary approach is to include all of the documentation in a single chart entry or template (Figure 4-2).

SOAP NOTE The SOAP note evolved from the POMR documenta-

tion format initially provided by Weed2 described in the preceding section. As with the POMR, the subjective section should include anything that the patient tells you pertaining to his or her injuries or problems. Subjective information can also be any information provided by the patient’s family or caregivers. The objective section should include the following: (1) results of screening procedures and tests and measurements performed, (2) the patient’s functional status, and (3) physical therapy interventions

Chapter 432

provided for that day of service. The interventions include procedural interventions, such as exercise and modali- ties, but should also include any collaboration with other disciplines and any patient or family education provided. The interpretation, or impression, has been designated A for assessment, and, in SOAP notes, the P stands for plan.

Examples of information provided in the S, O, A, and P portions of initial and interim notes can be found in Figures 4-3 through 4-6.

Unlike the POMR, one SOAP note includes information pertaining to all of the patient’s problems. Occasionally, the entire SOAP note is preceded by a problem (Pr) section. The

Date: 03/30/2017 Patient: David White Problem Associated Goal Current Status Intervention Plans 1. Pt. is unable to ascend and descend stairs.

Pt. will ascend and descend stairs with supervision and assistive device.

Pt. ascends and descends stairs with min (a) x 1 using the handrail PWB 50% (L) LE.

Ther ex: (B) LE strength- ening, weight shifting on/off the (L) LE x 15 minutes, stair training x 15 minutes.

Work on (B) LE strengthening, stair training.

2. Pt. is limited in mobility including ambulation.

Ambulate 200’ with crutches with (L) UE platform PWB 50% on (L) LE indepen- dently.

Pt. ambulates 100’ with crutches with (L) UE platform PWB 50% on (L) LE with min (a) x 1 to advance walker and verbal cues for weight bearing restric- tions.

Gait training x 15 minutes.

Continue to advance distance, decrease level of assistance provided.

Total time = 45 minutes Figure 4-2. More contemporary version of POMR.

Figure 4-3. Subjective.

Documentation Formats 33

Pr section contains information pertaining to the medical diagnosis, referral information, or information taken from the medical record (see SOAP Example later in this section). You will read more about the SOAP sections, including the Pr section, in subsequent chapters.

The SOAP format is a stand-alone format that has been widely used for some time and by a variety of medical and rehabilitation professionals. The SOAP format can be used for initial examinations and evaluations, interim documentation, and discharge documentation. The SOAP framework provides structure to medical record entries and should be used to show the clinical decision-making pro- cess in that patient/family complaints or remarks should be followed by related objective measures. Impairments, activ- ity limitations, or participation restrictions identified in the objective data should be interpreted in the assessment, and the plan should be aimed at remediating these identified impairments, activity limitations, or participation restric- tions. One contemporary modification of the SOAP note is seen in the initial documentation; the assessment and plan sections are blended into one section known as the plan of care.

SOAP Example Date: 03/30/2017 Patient: Davis White Pr: 27 y.o. s/p (L) wrist and ankle fx; Referral: Begin

gentle wrist and ankle AROM and PROM. S: Pt. RTC reporting no adverse effects from treatment

last visit or from HEP. He stated that his wrist and ankle are moving a little better and the edema in the hand has

decreased. He reports that he is able to shower (I) using a plastic chair in the tub and feels like he has improved with his ability to dress himself.

O: AROM: (L) wrist: flexion 30°, extension 30°, UD 15°, RD 20°, supination 45°, pronation 60°; (L) knee: 0–135°; (L) ankle: DF 0°, PF 45°. Girth: (L) wrist figure 8: 35.5 cm and (L) ankle figure 8: 43 cm. Tx: gentle AROM and PROM for 30’ to the (L) wrist and forearm for flexion, extension, supi- nation, and pronation; (L) ankle for DF, PF, inversion, and eversion; and for finger flexion and extension. Pt. ambu- lated 1000’ (I) with crutches using (L) UE platform, PWB 50% on the (L) LE.

A: Pt. has made improvements in AROM and has shown decreased edema. Also reports improved function at home in ADLs, self-care, and hygiene. Gait becoming more functional and (I).

P: Will continue to have pt. perform his HEP. He will RTC 04/05/2017 for safe exercise progression within the plan of care. Will also require stair training with assistance until patient in (I) and safe.

Bill Jones, PTA Even though SOAP notes provide a consistent and con-

cise documentation framework, they are often criticized for being very ineffective in providing details related to the patient’s need for skilled care, the patient’s function- al problems, or the clinician’s decision-making process. Historically, there have been issues with contents of a SOAP note. First, the subjective section often contained only information about the patient’s report of pain and his or her complaints. The objective section was written in terms of impairments rather than function. The assessment

Figure 4-4. Objective.

Objective (O)

Includes:

InterventionsData from the review of systems and relevant measures

Observation of patient perfor- mance of functional tasks

Consist of: Examples: Vital signs, measures of

impairment, performance-based func- tional measures

Functional status: i.e. gait, transfers, bed mobility, stairs

Coordination/ Communication

Procedural Interventions

Patient-Related Instruction

Discussion or coordina- tion of care with other disciplines, family, or

individuals involved with the patient

Instructions, training, or education provided by the patient and/or

family

Examples:

Physical or electrical agents, modalities,

therapeutic exercises, manual therapy

Airway clearance Integumentary

repair/Protective techniques

Functional training, training to reduce

impairments

Include modality, exercise or activity, equipment, sets, repetition, duration, frequency, targets tissue/area, position, dosage, and/or time

Chapter 434

became a place to write a vague response to treatment, such as “tolerated treatment well,” and the plan was also often written in very general terms, such as, “continue per plan.” Furthermore, the relationship between impairments and functional deficits were often implied rather than overtly stated in the assessment. In addition, interventions were rarely linked to the specific impairment or functional loss at which they were aimed, and the relationship between impairment reduction and improved functional capabili- ties was also implied rather than described in detail in the assessment section. These problems often resulted in docu- mentation centered around the patient’s complaints and impairments, rather than his or her functional changes.

Nevertheless, the SOAP format is widely known and used. It is integral to many documentation forms, templates, and electronic medical record systems. So, it is important to have a good understanding of the SOAP format compo- nents.

FUNCTIONAL OUTCOMES REPORTING The FOR is another documentation format, but its

emphasis is on patient function.1 Advantages of the FOR have been identified. The FOR clearly describes the rela- tionship between patients’ impairments and the ability to

Figure 4-5. Assessment.

Documentation Formats 35

perform functional tasks, and it improves readability for non-health care providers reviewing documentation.1,9

Authors have recommended integrating FOR into the SOAP structure described above by making the following additions to SOAP:

• Objective (O) section: Clearly and objectively describe the patient’s functional status, including functional activities that are specific to that patient, and docu- ment his or her impairments.9

• Assessment (A) section: (a) List only those impair- ments being addressed with therapy; (b) describe how improvement in impairments will lead to improvement in function; (c) provide complicating factors, or factors that could make the duration of services longer or dif- ferent from a typical case; and (d) physical therapists write goals using functional terminology.9

• Include the functional goal(s) at the top of daily and progress notes that were emphasized during that day of treatment (see example below).1

Functional Outcomes Reporting/SOAP Example

(Note: Following is the same example used to show the narrative, POMR, and SOAP formats. This example combines the FOR and SOAP formats as recommended by Abeln.9 Additions are presented in italics.)

Goals: (1) Increase AROM in the hand, wrist, and forearm to allow (I) with ADLs, work activities, and child care. (2) Increase ankle AROM to allow normal gait pattern.

S: Pt. RTC reporting no adverse effects from treatment last visit or from HEP. He stated that his wrist and ankle are moving a little better and the edema in the hand has decreased. He reports that he is able to shower (I) using a plastic chair in the tub and feels like his ability to dress himself has improved.

O: AROM: (L) wrist: flexion 30°, extension 30°, UD 15°, RD 20°, supination 45°, pronation 60°; (L) knee: 0-135°; (L) ankle: DF 0°, PF 45°. Girth: (L) wrist figure 8: 35.5 cm and (L) ankle figure 8: 43 cm. Functional Status: Gait: Ambulates household distances with (B) axillary crutches with (L) UE platform, PWB 50% (L), (I). Transfers: (I) with all transfers. Self-care: (I) with showering and dressing. IADLs: Unable to work; Unable to assist wife with child care duties. Tx: gentle AROM and PROM for 30’ to the (L) wrist and forearm for flexion, extension, supination, and prona- tion; (L) ankle for DF, PF, inversion, and eversion; and for finger flexion and extension. Pt. ambulated 1000’ (I) with crutches using (L) UE platform, PWB 50% on the (L) LE.

A: Pt. has made improvements in AROM and has shown decreased edema. Also reporting improved function at home in ADLs, self-care, and hygiene. Gait becoming more functional and (I). Decreased edema and exercise have improved AROM allowing improved use of wrist and hand during self-care and use of ankle for normal gait pattern. Continues to require use of crutches 2° to PWB status—this is limiting his ability to ambulate without an assistive device.

Bill Jones, PTA

Figure 4-6. Plan.

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TEMPLATES AND FILL-IN FORMS To facilitate documentation and eliminate time con-

straints, clinicians often use a variety of documentation templates and fill-in forms. Forms can be either paper or computer based. These forms not only save time, but also have potential to minimize writing, improve accuracy and consistency across patients, prompt clinicians to provide necessary data,10 and include essential documentation requirements set forth by Medicare or other third-party payers.11 Initial evaluations, daily and progress notes, re- evaluations, discharge summaries, and physician progress updates can be written using standard forms developed by individual facilities.

Forms and templates can also provide a mechanism for multidisciplinary documentation in which each discipline has its own section to complete on the same form. For example, in inpatient rehabilitation settings and in skilled nursing facilities, Medicare payment is determined by data provided through multidisciplinary fill-in forms. An example of a multidisciplinary form used in the assessment of skilled nursing facility residents is the minimum data set.12

While fill-in forms and templates often ease time con- straints and improve consistency, both physical therapists and physical therapist assistants must take care to not allow the form to “dictate” the session. This is especially important for students and new graduates, who may feel that they cannot deviate from the form. In some instances, clinical instructors and employers will require students and new graduates to document using one of the previ- ously described formats (ie, narrative, POMR, SOAP, FOR) rather than using the standard facility templates or fill-in forms. More important, forms can promote incomplete documentation.9,13 Providers must be sure that forms used not only contain all essential information, but also have areas where you are able to add narrative comments.13 These areas allow you to describe aspects of the patient’s care that are not part of the standard template or form. Remember all relevant aspects of the patient’s care must be documented, including characteristics unique to some patients that might not be part of the standard templates or forms. Another problem with templates is that they are often geared toward the patient population treated most at the facility. It might be difficult to use these forms when documenting on patients with less common diagnoses.

INDIVIDUALIZED FAMILY SERVICE PLANS AND INDIVIDUALIZED EDUCATION PLANS

The Individuals with Disabilities in Education Act (IDEA) is a federal law that governs states to provide a free appropriate public education for all children with dis- abilities residing in the state from birth to age 21.14 From

birth to age 3 years, the child is covered under IDEA Part C. Children who are considered “at risk” for developmental delay are referred to the program, and an initial evalua- tion is completed to determine a child’s eligibility.15 If the child is eligible for services under this legislation, he or she receives an Individualized Family Service Plan (IFSP). This is a special kind of multidisciplinary documentation that is reviewed on an annual basis to address the needs of the child. It includes the child’s present level of development, family concerns, results of outcome measures, anticipated goals, and types of services to be provided.15 A model IFSP can be found at https://www2.ed.gov/policy/speced/reg/ idea/part-c/model-form-ifsp.pdf.

Once the child turns 3, he or she may be eligible for coverage under IDEA Part B.15 This coverage lasts until age 21 years as long as certain eligibility requirements are met. Children and adolescents receive services under Part B to meet their educational needs and allow them to function in a general education environment. Under Part B of IDEA, there is a different kind of documentation known as an Individualized Education Plan (IEP). Like the IFSP, the IEP includes the child’s current academic and functional levels, a statement of his or her measurable goals, and the services that will be provided. The IEP also includes special accom- modations necessary for the child to improve chances for success.15 The IEP is also reviewed on an annual basis, at minimum. The web page http://idea.ed.gov provides resources including training for individuals involved in programs for school-aged children.15 Physical therapy ser- vices provided to children in the school system are geared toward enhancing the child’s function in the school to meet his or her educational needs. Services provided under this model are unique and differ from the medical model, where physical therapy services are most often delivered. Examples of school-based services include meeting seat- ing and positioning needs and addressing mobility issues in and around the school. A child who is getting services in the school system under an IEP may also be receiving outpatient physical therapy to address his or her medical needs.

Both the IFSP and IEP are somewhat analogous to the physical therapist’s initial plan of care in the medical model in that they serve as an outline of the expected outcomes and delineate services to be provided. Daily documentation in these settings also occurs at each encounter. In these set- tings, the documentation format often used is the POMR. Using this format, the physical therapist or physical thera- pist assistant can describe the treatment provided and the specific IEP or IFSP goal at which it is aimed.

REFERENCES 1. Quinn L, Gordon J. Functional Outcomes; Documentation

for Rehabilitation. 2rd ed. Maryland Heights, MO: Saunders Elsevier; 2010.

Documentation Formats 37

2. Weed LL. Medical Records, Medical Education, and Patient Care: The Problem-Oriented Medical Record as a Basic Tool. Chicago, IL: Year Book Medical Publishers; 1970.

3. Reinstein L, Staas WE, Marquette CH. A rehabilitation evaluation system which complements the problem-oriented medical record. Arch Phys Med Rehabil. 1975;56(9):396-399.

4. Reinstein L. Problem-oriented medical record: experience in 238 rehabilitation institutions. Arch Phys Med Rehabil. 1977;58(9):398-401.

5. Milhous RL. The problem-oriented medical record in reha- bilitation management and training. Arch Phys Med Rehabil. 1972;53(4):182-185.

6. Mcintyre N. The problem oriented medical record. Br Med J. 1973;2(5866):598-600.

7. Feinstein AR. The problems of the “problem-oriented medi- cal record”. Ann Intern Med. 1973;78(5):751-762.

8. Dinsdale SM, Mossman PL, Gullickson G Jr, Anderson TP. The problem-oriented medical record in rehabilitation. Arch Phys Med Rehabil. 1970;51(8):488-492.

9. Abeln SH. Improving functional reporting (utilization review). PT Magazine. 1996;4(3):26, 28-30.

10. Blecker D. Building better patient notes by using templates. ACD-ASIM Observer. 1998;18(9).

11. Feige M. Establishing standard rehabilitation evalua- tion forms. Arizona Association for Home Care. Caring. 1992;11(8):40-44.

12. Centers for Medicare & Medicaid Services. Minimum Data Set 3.0 public reports. CMS.gov website. https://www.cms. gov/Research-Statistics-Data-and-Systems/Computer-Data- and-Systems/Minimum-Data-Set-3-0-Public-Reports/ index.html. Updated November 14, 2012. Accessed July 9, 2017.

13. Lewis DK. Do the write thing: document everything. PT Magazine. 2002;10(7):30-34.

14. Individuals with Disabilities in Education Act of 2004, PL 108-446. 108th Congress (2004). http://idea.ed.gov/down- load/statute.html. Accessed July 9, 2017.

15. US Department of Education. Building the legacy: IDEA 2004. US Department of Education website. http://idea. ed.gov/. Accessed July 9, 2017.

Chapter 438

REVIEW QUESTIONS 1. List 4 documentation formats used in physical therapy.

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

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

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

5. When using SOAP and POMR formats, where should you place information provided by the patient’s family?

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

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

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

Documentation Formats 39

APPLICATION EXERCISES I. Read each statement below and determine whether it would belong in the S, O, A, or P portion of a SOAP note. 1. Gait: Ambulated 50’ x 2 WBAT (R) LE with min (A) x 1 and verbal cues to advance the (R) LE. 2. Pt. reports that the HEP has helped improve shoulder ROM. 3. Pt. will RTC for progression of his assistive device. 4. Transfers: bed to and from chair with mod (A) x 2. 5. Pt. progressing toward goals set on the initial evaluation. 6. Pt.’s wife stated that she has been assisting pt. with his HEP. 7. Speak with the PT about possible re-evaluation due to patient’s rapid progress. 8. AROM: (R) knee 0–135°. 9. Improvements in knee AROM allow pt. to sit without difficulty and ascend and descend stairs with less difficulty. 10. Pt. feels that he is benefiting from the strengthening exercises in that he is now able to open jars and lids (I). 11. Pt. will be seen for bid gait training to facilitate heel strike, increased step length on the (L) and decrease fall risk. 12. Pt. c/o inability to move her (L) UE and LE. 13. Pt. denies use of assistive prior to admission. 14. Gait distance improved from 25’ to 150’ over the last week. Pt. also requiring less verbal cueing. 15. Pt. demonstrating (L) neglect making her unsafe during gait and transfers. 16. Muscle Performance: All (R) LE strength is 5/5. 17. Vitals: HR 95 bpm, RR 12, and BP 140/95. 18. Pt. has improved ability to transfer in/out of bed since initial visit from mod (a) x 1 to supervision. 19. Will contact PT about possible d/c evaluation as pt. is no longer benefiting from the intervention. 20. Pt.’s endurance is poor due to COPD. 21. C/O inability to brush teeth and eat with the (R) hand due to decreased AROM of the (R) elbow. 22. Pt. is unable to drive or perform safe community mobility at this time due to mobility and ambulation restrictions. 23. Edema in the (R) ankle has decreased 2 cm. 24. Pt. dons/doffs prosthesis (I). 25. Wound appearance: 100% red, healthy granulation tissue with minimal drainage.

II. Of the above statements, which would be considered “functional”?

Chapter 440

III. Of the above statements, which link impairment to function?

IV. Your supervising physical therapist has asked you to work with a patient with the following problems: weakness in the left upper extremity, weakness in left lower extremity, dependence with ambulation, requires assist for all trans- fers, unable to perform self-care or home management skills.

1. List 3 questions that you could ask this patient when initiating a treatment session to elicit information for the subjective portion of a SOAP note.

2. What are 3 tests, measurements, or functional activities that you should document on this patient?

3. Compare and contrast SOAP, POMR, and FOR for this patient. What would be the same in all 3? What would be different? Which of these documentation formats would be most difficult to complete for this patient?

Mia L. Erickson, PT, EdD, CHT, ATC

Erickson ML, McKnight R. Documentation Basics for the Physical Therapist Assistant, Third Edition (pp. 41-48)

Electronic Medical Record

Chapter 5

After reading this chapter, the reader will be able to do the following: 1. Explain the reason for the growth in the use of the

electronic medical record (EMR). 2. Differentiate between EMR and electronic health

record (EHR). 3. Describe the benefits of EMRs and EHRs. 4. Describe the barriers to implementing the electronic

documentation. 5. Realize the use of electronic documentation in physical

therapy. The use of electronic patient records is growing.1 Many

physical therapists and physical therapist assistants are using computer-based documentation rather than hand- writing notes in a paper-based record or using transcrip- tion. One reason for this growth is due to federal legislation that provided incentives for Medicare and Medicaid pro- viders who were meaningfully using EHR technology.2 As of 2015, there were penalties, or a reduction in payment, for providers who were not demonstrating meaningful use.2 While physical therapists and physical therapist assistants

are not included in these incentives and penalties, physical therapy providers who want to collaborate with physicians or health systems will be expected to use systems compat- ible with the Meaningful Use Program.3 The definitions and stages for the Meaningful Use Program can be found on the Centers for Medicare & Medicaid Services website.4

The terms EHR and EMR are often used interchange- ably; however, the differences between the 2 are signifi- cant.5 The EMR is a digital version of the patient’s chart in a hospital or clinician’s office. It doesn’t easily travel outside of the clinic or facility that created it, and records need to be printed for a patient to be taken to a provider outside of the clinic.5 The EMR can take on a variety of formats. It can range from large, hospital-wide EMR systems, used by all providers in an organization, to small, individual physical therapy clinic-based systems that may or may not be con- nected to scheduling and billing. All systems vary in func- tionality, and, upon starting a job or a clinical education experience, one will need to become familiar with the EMR system used by the organization. The EHR is different. While the EHR does all of the things that the EMR does, its intention is to go beyond the clinic that collected the patient data and to allow the sharing of data between all of a patient’s health providers across multiple organizations.5

CHAPTER OBJECTIVES

KEY TERMS Electronic health record | Electronic medical record

KEY ABBREVIATIONS EHR | EMR

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In a systematic review published in 2006, the authors reported on the benefits of EHR systems that included improved reporting, operational efficiency, interdepart- mental communication, and data accuracy.6 More recent studies have identified additional benefits including the use of EHR data for developing patient registries that can be used for research7 and improved tracking of ancillary services and orders, legibility and accuracy, efficiency in insurance authorizations, and improved timeliness and accuracy of billing.8 Patients also have reported the positive benefits of being able to access their medical information.9

Barriers to EHRs have also been identified in the lit- erature. Vreeman et al6 reported workflow or behavior modification, hardware or software inadequacy, and staff training as barriers to implementation. In a 2016 systematic review of literature, Kruse et al10 reported the most fre- quently reported barriers, which included initial cost, tech- nical support, technical concerns, resistance to changing work habits, maintenance/ongoing costs, and training. In another 2016 paper describing barriers to the EHR, Chan et al11 reported similar barriers, but, in this study, the authors found that provider cooperation was the greatest barrier followed by costs and complexity of meeting Medicare’s Meaningful Use Criteria. In implementing the EHR, orga- nizations must be prepared for regularly scheduled system backups, upgrades, and maintenance of main and individ- ual computer terminals so that there is minimal disruption to the clinical workflow. There must also be processes for storing backup files so that critical information is not lost.

The Health Insurance Portability and Accountability Act (HIPAA) provides national standards for protect- ing an individual’s health information and for providing safeguards to maintain the security of protected health information and electronic health information.12 HIPAA will be discussed in more detail in Chapter 12. Maintaining privacy and confidentiality of EMRs can be accomplished in several ways. For example, computer terminals should be in private areas, laptops and tablets should be held or placed where they are not viewable by patients, or privacy screen filters should be used. Computer systems maintain- ing patient records must be password protected with strong passwords and secured to prevent unauthorized use and assure private transmittals. They should “time out” after a brief period of nonuse.

Regardless of the security and privacy rules, data breach- es occur. Data breaches can cost companies millions of dol- lars and can result in civil or criminal charges. The Privacy Rights Clearinghouse, a nonprofit organization that serves to empower consumers to protect their privacy, reported over 500 data breaches in the health care and medical industry in 2016 that affected nearly 4 million records.13 Breach categories include unintended disclosure, hacking or malware, payment card fraud, insider (eg, employee, former employee), physical (eg, lost, discarded, stolen non- electronic records), and portable device.14

PHYSICAL THERAPY AND THE ELECTRONIC MEDICAL RECORD

In physical therapy practice settings, using electronic documentation, the initial examinations/evaluations, daily and progress notes, re-evaluations, and discharge sum- maries are created using the computer documentation software. Some software packages can generate notes to the physician or case manager populated by previously recorded patient data. Physical therapy professionals log in to the software and create documentation by entering in data through templates built into the system’s infra- structure. Templates are often based around body systems, regions, or pathologies. There are software packages that will allow clinicians to create their own templates around a frequently treated specific condition or patient population. Data are entered through checking boxes, selecting from a pull-down menu, or free texting into fill-in forms (Figure 5-1). Templates are often created using the SOAP (subjec- tive, objective, assessment, and plan) format (introduced in Chapter 4), and that is why it is important to have an understanding of the SOAP contents. Figures 5-2 through 5-5 show screen shots from an EMR designed for physical therapy. Research suggests that the use of templates and standardized forms built into computerized documenta- tion systems can help produce more complete and accurate documentation and can facilitate data mining for second- ary use purposes such as research and quality reporting.15

Whether you are practicing at a large hospital system or a small private practice, the interface and functional- ity for every software package is different, and one will be required to take time to learn how to navigate the software. It is essential to understand the required elements of a good note so that, after one learns the navigation and interface, he or she will be able to input the necessary components and information. Also, one must recognize that it is dif- ficult to capture some aspects of the episode of care in a pre-established template. For example, both medical neces- sity and the need for skilled care are difficult to articulate in check boxes and drop-down menus, especially when the patient is complex. There are also times when the complex patient’s case does not fit easily into the computerized tem- plates. Some information may need to be free typed into the software because of its importance. It is also important that clinicians do not get into a routine of documenting the same things for every patient, as software can prepopulate fields from previous visits and generate standard phrases. Notes can quickly start appearing the same for every visit and for every patient.

Electronic Medical Record 43

Figure 5-1. Sample electronic medical record interface.

Figure 5-2. The “Subjective” tab from the daily note. This is the section where the clinician finds and updates the note’s date and the patient’s diagnosis, and adds subjective remarks. This information carries forward from note to note, eliminating double data entry. (Reproduced with permission from WebPT™ [Phoenix, AZ].)

Chapter 544

Figure 5-3. The “Objective” tab from the daily note. This section includes check boxes that link provided services to their corresponding billing codes. Those codes then automatically appear on the billing sheet associated with that daily note. Because the treatment is described within the note, you can easily make your selections and bill without having to memorize a long list of billing codes. (Reproduced with permission from WebPT™ [Phoenix, AZ].)

Electronic Medical Record 45

Figure 5-4. The “Assessment” tab from the daily note. One may create problems and goals that will carry forward from note to note. This makes updat- ing progress both simple and efficient. (Reproduced with permission from WebPT™ [Phoenix, AZ].)

Chapter 546

Figure 5-5. The “Plan” tab from the daily note. One selects a plan from the dropdown menu that includes commonly used treatment instructions. If more detail is needed, one then describes the plan using the expandable box below the dropdown list. (Reproduced with permission from WebPT™ [Phoenix, AZ].)

Electronic Medical Record 47

REFERENCES 1. American Physical Therapy Association. Electronic health

records (EHR). APTA website. http://www.apta.org/EHR/. Updated May 18, 2016. Accessed July 10, 2017.

2. Centers for Medicare & Medicaid Services. Medicare and Medicaid EHR incentive program basics. CMS.gov website. https://www.cms.gov/regulations-and-guidance/legislation/ ehrincentiveprograms/basics.html. Updated January 12, 2016. Accessed July 10, 2017.

3. American Physical Therapy Association. Electronic health records. APTA website. http://www.apta.org/EHR/. Updated May 18, 2016. Accessed October 16, 2017.

4. Centers for Medicare & Medicaid Services. Electronic health records (EHR) incentive programs. CMS.gov web- site. https://www.cms.gov/Regulations-and-Guidance/ Legislation/EHRIncentivePrograms/index.html?redirect=/ EHRincentivePrograms/. Updated June 20, 2017. Accessed July 10, 2017.

5. Garrett P, Seidman J. EMR vs EHR—what is the difference? Health IT Buzz website. https://www.healthit.gov/buzz-blog/ electronic-health-and-medical-records/emr-vs-ehr-differ- ence/. Updated January 4, 2011. Accessed July 10, 2017.

6. Vreeman DJ, Taggard SL, Rhine MD, Worrell TW. Evidence for electronic health record systems in physical therapy. Phys Ther. 2006;86(3):434-449.

7. Anderson AJ, Click B, Ramos-Rivers C, et al. Development of an inflammatory bowel disease research registry derived from observational electronic health record data for compre- hensive clinical phenotyping. Dig Dis Sci. 2016;61:3236-3245.

8. Bobadilla JL, Roe CS, Estes P, Lackey J, Steltenkamp CL. Leveraging electronic health record implementation to facili- tate clinical and operational quality improvement in an ambulatory surgical clinic. J Ambulatory Care Manage. 2017;40(1):9-16.

9. White H, Gillgrass L, Wood A, Peckham DG. Requirements and access needs of patients with chronic disease to their hospital electronic health record: results of a cross-sectional questionnaire survey. BMJ Open. 2016;6(10):e012257.

10. Kruse CS, Kristof C, Jones B, Mitchell E, Martinez A. Barriers to electronic health record adoption: a systematic review. J Med Syst. 2016;40(12):252.

11. Chan KS, Kharrazi H, Parikh MA, Ford EW. Assessing elec- tronic health record implementation challenges using item response theory. Am J Manag Care. 2016;22(12):e409-e415.

12. Office for Civil Rights. US Department of Health & Human Services. Summary of the HIPAA Security Rule. https://www. hhs.gov/hipaa/for-professionals/security/laws-regulations/ index.html?language=es. Accessed July 10, 2017.

13. Privacy Rights Clearinghouse. Chronology of Data Breaches. San Diego, CA: Privacy Rights Clearinghouse. https://www.privacyrights.org/data-breaches?title=&org_ t y p e % 5 B % 5 D =2 5 8 & t a x o n o m y_ v o c a b u l a r y_ 11 _ tid%5B%5D=2257. Accessed October 20, 2017.

14. Blanke SJ, McGrady E. When it comes to securing patient health information from breaches, your best medicine is a dose of prevention: a cybersecurity risk assessment checklist. J Healthc Risk Manag. 2016;36(1):14-24.

15. Vuokko R, Makela-Bengs P, Hypponen H, Lindqvist M, Doupi P. Impacts of structuring the electronic health record: results of a systematic literature review from the perspec- tive of secondary use of patient data. Int J Med Inform. 2017;97:293-303.

Chapter 548

REVIEW QUESTIONS 1. Give one reason for the growth in the use of the EMR and the EHR.

2. What is the difference between the EMR and the EHR?

3. What are the benefits of the EMR and the EHR?

4. What are the barriers to implementing the EMR?

5. Describe the benefits of templates built into the EMR.

6. Describe the issues related to prepopulated fields.

7. What are positive and negative aspects of using check boxes, dropdown menus, and smart phrases?

8. Investigate Medicare’s Meaningful Use Criteria. What are the stages? Provide some examples of what is required in each stage that could be relevant to physical therapy practice.

9. Research some EMR systems used in physical therapy. What are the features associated with each?

10. Interview a clinician who uses an EMR. Explore his or her opinion on the EMR and what he or she likes and dislikes. If the clinician has been part of a transition from paper to electronic records, discuss the changes that occurred in the workflow.

Rebecca McKnight, PT, MS and Mia L. Erickson, PT, EdD, CHT, ATC

Erickson ML, McKnight R. Documentation Basics for the Physical Therapist Assistant, Third Edition (pp. 49-57)

Basic Guidelines for Documentation

Chapter 6

After reading this chapter, the reader will be able to do the following: 1. List components of the Patient/Client Management

Model that should be documented in the medical record.

2. Identify tasks that must be documented by the physi- cal therapist and those that can be documented by the physical therapist assistant.

3. Discuss basic principles for documentation. 4. Discuss principles for documenting patient care. 5. Correctly document late entries and appropriate cor-

rect errors in written medical records. 6. Follow appropriate guidelines when creating physical

therapy documentation.

DOCUMENTATION IN PHYSICAL THERAPY Documentation of physical therapy services occurs

over a continuum, throughout a patient’s episode of care. Documentation begins with the initial examination, evalu- ation, and plan of care as performed and written by the

physical therapist. Subsequent documentation includes interim notes for every encounter with the patient. Interim notes can be written by the physical therapist or the physi- cal therapist assistant. Interim notes are written to record treatment sessions and serve as a record of what was billed. Progress notes are written to reflect the patient’s progress toward the goals stated in the initial evaluation, as the patient’s status changes, or within a required time frame as dictated by state law or third-party payers. Final documen- tation is performed at the summation of care. This is the last entry in a patient’s record and is usually referred to as the discharge summary. This note often reflects the results of a discharge evaluation, which is also performed and written by the physical therapist. From examination to dis- charge, the physical therapy record should reflect the fol- lowing: (1) the patient’s condition or pathology; (2) impair- ments, activity limitations, and participation restrictions identified through appropriate tests and measurements; (3) anticipated goals and expected outcomes; (4) interventions provided, including patient education, communication with other disciplines, and specific procedural interven- tions; and (5) the final outcome or result of the interven- tion. The American Physical Therapy Association (APTA) official position on documentation states the following1:

CHAPTER OBJECTIVES

KEY TERMS Addendum | Authentication | Late entries

KEY ABBREVIATIONS APTA

Chapter 6

Physical therapy examination, evaluation, diagno- sis, prognosis, and plan of care (including inter- ventions) shall be documented, dated, and authen- ticated by the physical therapist who performs the service. Interventions provided by the physical therapist or selected interventions provided by the physical therapist assistant under the direction and supervision of the physical therapist are docu- mented, dated, and authenticated by the physical therapist or, when permissible by law, the physical therapist assistant.

In addition, the medical record should be kept in a secured file to meet confidentiality, privacy, and security requirements.

The APTA has set forth standardized Guidelines: Physical Therapy Documentation of Patient/Client Management.2 These guidelines do not reflect the documentation needs of all specialty areas, but rather provide a foundation for developing more specific documentation procedures across a variety of unique and specialized settings.2 Other authors have also reported specific guidelines for documenting in medical records.3-10 This chapter discusses basic principles for documenting in a medical record.

BASIC PRINCIPLES • Be timely. It is important that documentation is

completed as soon after the session as possible. First, the treatment session is fresh in one’s mind, and one is more likely to remember details sooner after the session rather than later. In addition, documentation will be necessary so that another physical therapist or physical therapist assistant can treat the patient in the event of an absence. There are also administrative reasons for timely documentation. These include filing reimbursement claims and sending progress updates to others involved in the patient’s care, including physicians, case managers, or insurance companies. Clinics are likely to have policies in place that require the completion of all patient documentation within a given time frame.

• Be thorough, relevant, accurate, and logical. A reviewer should be able to examine the medical record and have an accurate, detailed portrayal of the patient and situation. Again, another physical therapist or physical therapist assistant should be able to look at the patient’s record and treat the patient in the case of your absence.

• Be clear and concise. Although it is important to be as concise as possible, you should also still be thorough. Never leave out pertinent information for the sake of brevity.

• Be consistent. Use similar documentation formats throughout the patient’s episode of care at your facil- ity (eg, forms, SOAP, format, flowsheets). This makes

it easy for reviewers and other health care providers to locate necessary information. Templates come built into electronic medical records and, in some software, templates can be created or loaded. Using templates can help with consistency.

• Use objective language. Include facts and observa- tions. Avoid making subjective remarks about patients, including anything that cannot be substantiated by the data. This includes subjective remarks about a patient’s response to a treatment (eg, “tolerated treatment well”), the patient’s personality, or his or her psychological status. Also, avoid subjective terms such as appears and seems to be (eg, “patient seems depressed today”).10 Although you may be trying to provide additional information about the patient, be very careful not to make an unsubstantiated judgment, or a judgment outside of the scope of one’s professional training and knowledge.7

• Write legibly. While the majority of physical therapy documentation occurs electronically, there may be instances when notes must be handwritten and they should be written legibly. Third-party payers have been known to deny claims based solely on the fact that they could not read the provider’s handwriting.

• When writing in a medical record, or creating docu- ments that will be scanned into a medical record, use black or blue permanent ink. Ballpoint pens are preferred over felt tip pens. Erasable ink should never be used.

• Use scientific, medical terminology and avoid “non- skilled language.” For example, avoid statements such as, “The patient walked.” Instead, use descriptive, objective, functional language that emphasizes what the patient or family member/caregiver did. For exam- ple, use statements such as the following:

º “The patient ambulated 50’ with assistance x 1 at the truck to maintain upright posture.”

º “The patient stood in the parallel bars x 2 minutes equal weightbearing on (B) LEs without loss of balance.”

º “The patient’s wife was able to (I) transfer the patient from the bed to the bedside commode upon return demonstration.”

º “Upon return demonstration, the patient’s care- giver was able to provide passive stretching to the patient’s heel cords (I) after instruction.”

• When documenting interventions, include specific descriptions of the intervention, equipment used, number of sets, number of repetitions, treatment parameters, and any other details necessary for another therapist to recreate the session. Flowsheets may be used as long as there is a corresponding writ- ten note describing both the skilled services provided to the patient for that day of service and the patient’s response to treatment for that day of service.

Basic Guidelines for Documentation 51

• Communicate skilled care. Describe how the skills of the therapist were used to assist the patient. Use specific language to allow the reader to understand how the therapist’s special skills and training provided assistance to the patient above and beyond what could be provided by an untrained individual. A descrip- tion of how the therapist’s skills assisted the patient provides important information for a reviewer and provides data to support the patient’s need for skilled services. The following are some examples:

º “The patient ambulated 25’ with a quad cane. The patient required min (a) x 1 for facilitation to the (R) quadriceps during the swing phase of gait and min (a) x 1 for stabilization of the (R) knee during the stance phase.”

º “The patient required instruction in safe and effec- tive walker use during treatment so that he could maintain weightbearing restrictions and perform safe step length.”

• Use abbreviations appropriately. Use only industry- standard and facility-approved medical terminology, symbols, and abbreviations. Do not create your own abbreviations. Also, do not overuse abbreviations or symbols. This can become confusing for the reader, especially if he or she is unfamiliar with the abbre- viations. Most word processors used in EMRs prevent the use of many symbols. In addition, some abbrevia- tions have more than one meaning (eg, PT = physical therapist and prothrombin time). In these cases, one must read the entire note to determine the context of the abbreviation so that it can be interpreted correctly. Most facilities will have policies regarding acceptable abbreviations and their use. Common abbreviations and symbols have been provided in Appendix A.

• When handwriting an entry for a medical record, avoid skipping lines. Do not skip lines in the middle of entries, such as in between different sections. Skipping lines could allow someone to come back at a later date and fraudulently add information.

• Use headings. Headings group relevant information together to indicate new sections and to designate important patient information. They often make the note easier to read, and they identify necessary infor- mation. When handwriting notes, it is important to use the same headings that were used by the physical therapist in the initial evaluation, when possible. This will help to provide consistency between the initial evaluation and the interim notes and will allow the reader to identify data in specific sections. The use of headings is often necessary in instances when the health care providers must free text their notes into a word processing area. In the EMR, headings are often prepopulated and appear on the printed version of the note.

• Use tables when indicated. In instances when there are great deals of data that can easily become confus- ing to the reader, it is appropriate to use tables, col- umns, or lists. Tables are valuable when documenting range of motion or strength on several joints, such as the hand. The EMR will print reports placing data in table format, where appropriate.

• Document late entries. After completing the docu- mentation for a particular treatment session and plac- ing it in the medical record, one might realize a need to document additional information about the session. The original note should never be rewritten. Instead, complete a late entry. The entry should be placed in chronological order for the date that it is written and should be identified as a “late entry” or “addendum.”

• When handwriting entries, correct errors with a single straight black line through the text. Initial and date next to the error. Never use correction fluid in an entry for a medical record. An individual reading the note should still be able to read what was written origi- nally (eg, “The patient ambulated MLE 2/18/17 trans- ferred from the bed to the chair with min (A) x 1 to guard at the knee to prevent buckling during stance”).

• Date and authenticate all patient records. All physi- cal therapy records should be dated according to the day that the services were provided. Authentication is defined as “the process used to verify that an entry into the medical record is complete, accurate, and final.”2 Indications of authentication can include original written signatures or electronic signatures. Signatures should also include the clinician’s full name and desig- nation (PT or PTA).5

• Document missed appointments. Document reasons for cancelled or missed appointments or treatment sessions, whether initiated by the patient, the physical therapist, the physical therapist assistant, or another health care provider.

º Example 1: In an outpatient clinic, a snow storm in January

caused your patient to miss 2 appointments. Document:

■ 1/19/17—Pt. canceled appt. due to weather, rescheduled for 1/21/17. Sue Brooks, PTA

■ 1/21/17—Pt. canceled appt. due to weather rescheduled for 1/23/17. Sue Brooks, PTA

º Example 2: On a skilled nursing unit, the nurse asks that

you not work with a patient because the physician suspects that the patient has a “blood clot” and is awaiting a Doppler study. Document:

■ 12/12/17—Attempted to see Mrs. Smith this am; however, nursing asked that we hold ther- apy 2° to possible DVT, awaiting Doppler. Will resume when cleared. Sue Brooks, PTA

Chapter 652

• Document telephone, face-to-face, or e-mail con- versations related to patient care. This could include conversations with the patent, the patient’s family, the physician, other health care providers, or case managers.

• Document unusual or unexpected situations or results. Some of these situations may also require the completion of an incident report. (The completion of incident reports will be discussed further in Chapter 12 within the discussion of legal aspects of documenta- tion.) For example, you are working with a 22-year-old woman who underwent an anterior cruciate ligament repair. She is performing resisted knee flexion with a pulley system and feels a “pop” in her knee with a moderate increase in pain.

• When handwriting notes, indicate “continued” when using more than one page. When the documentation of patient care requires more than 1 written page, make sure that each page includes the patient’s name, the patient’s medical record number, and the date. You should transition the information by writing a state- ment such as, “PT note for [patient’s name and date] continued next page,” or “PT note for [patient’s name and date] continued from previous page.”

DOCUMENTING PATIENT CARE • Record the patient’s comments using terms provided

by the patient and include changes in status. It is important to record the patient’s perceptions of how the intervention is bringing about change and the rele- vant changes in function that he or she has noticed. For example, one may record the following: “The patient states that his exercises have helped in improving knee motion, and he is noticing improvement in sitting and ascending/descending stairs as a result.”

• Integrate disablement. Use common, profession- al terminology consistent with the International Classification of Functioning, Disability and Health Framework.11 Perform relevant tests and measures that are consistent with the initial examination, and record the patient’s status in terms of impairments, activity limitations, and participation restrictions. Describe how the impairments are leading to activity limitations and participation restrictions. For example, one may record the following: “The patient’s decreased elbow flexion is limiting his ability to brush his hair, brush his teeth, and feed himself.”

• Make comparisons between data collected at inter- im visits with data collected at the initial visit. Also, make comparisons between data collected at the beginning of a treatment session and data collected at the conclusion of the session. This can help to show patient progress and the need for further intervention.

• When documenting planned interventions, docu- ment the rationale. For example, one may record the following: “Plan to implement electrical stimulation at the next visit to increase activity of the wrist extensor muscles.”

• Document patient education. This includes doc- umenting any precautions, limitations, restrictions, or instructions provided to the patient. Also, as a rule, document the patient’s response or how the patient portrayed an understanding of the instructions provided. One may document the following, “After reviewing total hip precautions, the patient was able to recite them without correction, and the patient verbal- ized understanding.”

• Document so that the notes are in compliance with the state’s Physical therapy practice act. Upon licen- sure, review the practice act to identify any specific requirements related to documentation. See http:// www.apta.org/Licensure/StatePracticeActs/ for a list of practice acts by state.

• Document planned interventions without being repetitive. One should not use the phrase “continue per plan” for multiple subsequent visits, but instead should be specific as to what skilled intervention will be provided at the next visit. Documenting the same information in the plan on several notes is received as being repetitive. It may also trigger an audit to deter- mine if care is reasonable and necessary.

REFERENCES 1. American Physical Therapy Association. Documentation

Authority for Physical Therapy Services. HOD P05-07-09- 03. https://www.apta.org/uploadedFiles/APTAorg/About_ Us/Policies/HOD/Practice/Documentation.pdf. Updated December 14, 2009. Accessed November 14, 2016.

2. American Physical Therapy Association. Guidelines: Physical Therapy Documentation of Patient/Client Management. BOD G03-05-16-41. https://www.apta.org/ uploadedFiles/APTAorg/About_Us/Policies/BOD/Practice/ DocumentationPatientClientMgmt.pdf. Updated December 14, 2009. Accessed July 11, 2017.

3. Redgate N, Foto M. Pay by the rules: avoid Medicare audits and reduce payment denials with a sound strategy and prop- er documentation. Physical Therapy Products. 2003;October/ November:28-30.

4. Inaba M, Jones SL. Medical documentation for third-party payers. Phys Ther. 1977;57(7):791-794.

5. Goode N. The reliable resource: physical therapy documen- tation. PT Magazine. 1999;7(9):30-31.

6. Lewis DK. Do the write thing: document everything. PT Magazine. 2002;10(7):30-34.

7. Schunk CR. Liability awareness. Advice for the new physi- cal therapist: here are some keys to avoiding risk once you’ve made the transition from student to practitioner. PT Magazine. 2001;9(11):24-26.

Basic Guidelines for Documentation 53

8. White JA. Documentation: making it meaningful. Physical Therapy Case Reports. 2000;3(2):78-79.

9. Abeln SH. Liability awareness. Reporting risk check-up. PT Magazine. 1997;5(10):38-42.

10. Clifton DW. “Tolerated treatment well” may no longer be tolerated. PT Magazine. 1995;3(10):24.

11. World Health Organization. International Classification of Functioning, Disability and Health. Geneva, Switzerland: World Health Organization; 2001. http://apps.who.int/iris/ bitstream/10665/42407/1/9241545429.pdf. Accessed July 2, 2017.

Chapter 654

REVIEW QUESTIONS 1. What components of the Patient/Client Management Model should be documented in the medical record?

2. What is the purpose of the APTA Guidelines: Physical Therapy Documentation of Patient/Client Management?

3. In a written medical record, what color ink is most appropriate?

4. A physical therapist assistant sees a patient in an acute care setting first thing in the morning. When is the most appropriate time to document the session?

5. A physical therapist documents an initial examination and evaluation using the SOAP format. In most cases, sub- sequent documentation should take which format?

6. How might an entry be written so that it communicates that the care the patient received is “skilled”?

7. When is it appropriate to create your own abbreviations or symbols for use in a medical record?

8. Give an example of how an error should be corrected when handwriting a note.

9. What documentation format would be appropriate to document cancellations or missed appointments?

10. How might a physical therapist assistant document patient progress? Give an example.

11. How might a physical therapist assistant integrate disablement into the patient’s medical record? Give an example.

12. Give an example of a medical record entry that includes a planned intervention and a rationale.

13. When is it appropriate to document, “continue per plan”?

14. Give examples of information that a physical therapist assistant might record in the assessment section of a SOAP note.

Basic Guidelines for Documentation 55

APPLICATION EXERCISES I. For the following entries, indicate examples that are inappropriate by writing an “I” next to the item. Describe why

they are inappropriate. Pt. walked 50’. Skilled services are needed. Pt. stated that she enjoys coming to PT. Pt. c/o pain in the (L) knee following exercise after the last visit. AROM: (R) shoulder flexion 160° abduction 120°. Pt. performed QS, GS, and SLRs. Pt. walked around the PT gym 2 x. ROM: knee 0° to 135°. Pt. is demonstrating global aphasia. Pt. is demonstrating excessive hip abduction with his prosthesis during ambulation. Gait: 100’ with hemi walker and min (A) x 1 for trunk support and min (A) x 1 for advancing the (L) LE. Transfers: bed <–> chair with min (A) x 1 due to poor balance. Ther Ex: Performed 20 repetitions all exercises. Bed mobility: Rolls supine <–> side lying with min (A) x 1. HEP: Instructed pt. in a HEP to be performed tid.

II. Write the following information in a more clear and concise manner, as it would appear in the medical record. Include an appropriate subheading.

1. The patient walked 75 feet in the hallway of the hospital with the therapist lightly touching her back. She used a front-wheeled walker. The therapist was needed to help provide the patient with support to maintain balance.

2. The patient’s strength was 3/5 for the right biceps and 4/5 for the right triceps.

3. Upon arrival to therapy, the patient told you that she had been doing her HEP without any problems and really felt like her ability to get in and out of bed has improved.

4. The patient said that her pain was 3/10 on a pain scale.

5. You performed an ultrasound to the dorsal aspect of the patient’s right foot. You used 3 MHz at 50% duty cycle with the intensity set at 1.0 w/cm2.

6. The patient demonstrated the following range of motion measurements: active range of motion for the right elbow was 130° flexion and 10° of hyperextension.

7. Knee active range of motion was 100° flexion and lacking 10° of extension.

Chapter 656

8. The patient propelled his wheelchair around the hospital, outside on the sidewalk, and up and down several ramps with you providing verbal reminders on trunk positioning for going up and down the ramps.

9. The patient was able to put her ankle-foot orthosis on and remove it independently. She was also able to indepen- dently check her skin for any irritated areas after she removed the orthosis.

10. You instructed the patient to perform 10 repetitions of each exercise as part of her home exercise program. The exercises included ankle pumps, quadriceps setting, short arc quadriceps strengthening from 45° to 0°, and heel slides.

11. During a busy morning in a hospital, you were working with a patient who told you that she was going to be dis- charged and wanted home health services, primarily physical therapy. After writing the note and moving on to the next patient, you realize that you did not document the patient’s desire for home therapy. What should you do? How would you document this entry into the medical record. Where should this information be placed? How might this be different if you were using an EMR?

12. When handwriting information in the medical record, you realize that you made an error in documenting the patient’s AROM. It should have been 125°, not 152°. Demonstrate how to correct this mistake.

III. Organize the following information so that it is clear, concise, and suitable for entry into the medical record using the SOAP format. Indicate whether the information would fall into the S, O, A, or P portion of the note. Use sub- headings where appropriate.

1. Mr. Jones comes into the clinic today and tells you that his fingers became swollen and that he has had pain at a level of 7 out of 10 since the last treatment session. He goes on to say that he has not been able to perform any of the range of motion exercises you gave him because of the incredible amount of pain he has been having. He said that he has changed his postoperative dressing once a day since the last visit, and he has had a little bit of red drainage on the bandages. He also said that he is having trouble eating and shaving due to the swelling and stiff- ness in the finger joints.

2. You enter Mrs. Smith’s hospital room and ask her if she is ready for treatment. She agrees and tells you that she wants to be ready to walk down the aisle at her grandson’s wedding without using her walker. She said that her right knee pain is not as bad as it was yesterday and she thinks that she is able to bend it more. She goes on to say that she has performed the range of motion exercises twice already this morning, and she is working on trying to get her knee to bend as much as she can. While walking using a standard walker, she asks if she can begin using a cane soon.

3. Mr. Smith comes into the physical therapy department and tells you that he notices improvement in his walking since beginning the active range of motion exercises for his ankle. He also says that he is having 0 out of 10 pain with the new exercises. He goes on to tell you that he still has pain when walking on gravel, carpet, and stairs. His job requires him to do a lot of walking on uneven terrain, and he wants to be able to do this without pain before returning to work.

Basic Guidelines for Documentation 57

4. You are assigned an inpatient who had a right cerebral vascular accident 3 weeks ago. The supervising physical therapist told you that the patient is demonstrating confusion and slurred speech, but her daughter is usually present during the sessions. Upon entering the patient’s room, you notice that the daughter is not present. As you work with the patient, she tells you that she fell in the bathroom last night. She also tells you that she is afraid to get out of bed because of her fear of falling again. It was difficult for you to understand the patient due to the slurring. You also understand the patient when she says that her left shoulder is sore. While performing bedside active assistive range of motion, her daughter returns, and you comment to the daughter about the patient’s fall the previous night. The daughter tells you that there wasn’t a fall and that she had been there with her mother all night.

5. While treating a patient during a home health visit, the patient’s son tells you that his mother (the patient) has been up all night due to left hip pain. He also tells you that he is having trouble getting his mother to walk in the house with him due to pain and fear of making her hip hurt more than it already does. He also says that he has trouble performing the range of motion exercises that you showed him during the last session. The patient tells you that, because of the pain, she feels like her hip is going to give out when she stands on it.

6. Passive range of motion measurements were as follows: Right knee flexion 100°, right knee extension 5°, hip abduction 20°, hip flexion 100°, ankle PF 20°, elbow 10° to 100°, shoulder flexion 100°, shoulder abduction 100°, hip IR 20°, ankle DF 5°, shoulder ER 60° and IR 45°.

7. The patient walked 10’, twice, with 1 person supplying 25% assistance, used a standard walker, did not put any weight on the right leg, needed verbal reminders each time for placing the walker forward.

8. The patient went up and down 4 stairs with a handrail that was on the right side going up and on the left coming down; the patient used a straight cane. He required supervision from the physical therapist assistant.

9. The patient walked with the therapist at his side (but not touching him) for 100 feet, twice; vital signs before exercise were blood pressure 125/85, 15 for respirations, and 77 for heart rate; vitals after were 135/85 for blood pressure, 17 for respirations, and 87 for heart rate; the patient performed ankle pumping, elbow flexion, shoulder flexion, and knee extension for 10 repetitions before and after exercise.

10. The patient’s girth at the right knee joint line was 34 cm, 2 inches above was 38 cm, 4 inches above was 42 cm, and 4 inches below was 35.5 cm. Active flexion was 120°. The patient lacked 20° of active extension. Hip and ankle active range of motion were within normal limits. Strength for the quadriceps muscle was 3-/5 and for the hamstring was 3-/5. The patient walks independently with crutches, weightbearing as much as he can tolerate on the involved extremity for 100 feet.

Rebecca McKnight, PT, MS

Erickson ML, McKnight R. Documentation Basics for the Physical Therapist Assistant, Third Edition (pp. 59-78)

Interpreting the Physical Therapist Initial Evaluation

Chapter 7

After reading this chapter, the reader will be able to do the following: 1. List the types of information that can be found in each

component of an initial evaluation note. 2. List the questions that the physical therapist assistant

should ask when reviewing the evaluation note to guide decision related to provision of selected inter- ventions.

3. Locate and use information in the initial evalua- tion note to determine which interventions are to be provided and how those interventions need to be performed.

4. Locate and use information in the initial evaluation note that will assist the physical therapist assistant in judging the patient’s performance and outcomes and determining what course of action needs to be taken.

It was a bright July morning. Sarah approached the outpa- tient physical therapy clinic with a feeling of excitement and an air of expectation. This would be her first day of patient care as a licensed physical therapist assistant. As excited as she was, Sarah was also nervous. She knew that she had

an important role to play in her new position, and now she no longer had a clinical instructor or her college teachers helping her to make decisions. Questions swirled through her mind as she walked in the door. “Am I really ready for this?” “Will I remember what I learned?” Her apprehen- sion doubled as she met with John, her supervising physical therapist. As John began to discuss with Sarah the patient care activities that he was directing her to perform that day, her questions continued to trouble her. “Will I know what to do with the patients I will be working with?” “Will the inter- ventions I provide be effective?” “Will John have confidence in my abilities?” Sarah’s anxiety followed her throughout the morning until she sat down to review the chart for her first patient, S.S. As she read the information about S.S., she realized that she knew exactly what to do, and she was able to approach her first patient that morning with confidence.

Sarah was confident as she began her day of patient care because she had a clear understanding of the physical therapy process and her role in it. Based on this under- standing, Sarah knew what was expected of her, and she knew what to expect from John, her supervising physical therapist. Sarah’s knowledge allowed her to be able to use the communication tool of the physical therapist initial evaluation to determine how she would proceed with S.S.’s

CHAPTER OBJECTIVES

KEY TERMS Documentation | Episode of care | Initial evaluation note | Record of care | SOAP note

KEY ABBREVIATIONS SOAP

Chapter 7

care that day. In this chapter, we take a closer look at the physical therapist initial evaluation note. We then discuss how you, as a physical therapist assistant, will use the initial note to determine how to proceed with providing selected interventions as directed by the physical therapist.

DOCUMENTATION CONTINUUM IN PHYSICAL THERAPY

As noted in Chapters 2 and 6, documentation of physical therapist services should occur across the episode of care. The following 4 types of notes that may be a part of the patient’s physical therapist care record: (1) initial evalua- tion, (2) interim notes, (3) re-evaluation, and (4) discharge summary. The only type of note that might not be found in a patient record is a re-evaluation. A re-evaluation may not be required when a patient progresses in a smooth and uninterrupted fashion within a short time frame. The other 3 types of documentation must be found in a patient’s physical therapist record of care. The initial evaluation is documented at the initiation of care and includes the examination, evaluation, diagnosis, prognosis, and plan of care. Interim notes, also known as visit/encounter notes, progress notes, daily notes, or treatment notes, occur at regular intervals throughout the patient’s episode of care and records intervention activities, patient’s responses and progress, and any other information necessary to create a clear picture of the patient’s need for and response to skilled interventions. Daily or treatment session notes should be completed by the individual providing the interventions, whether it is the physical therapist or the physical thera- pist. Progress notes are often summaries of the physical therapy care to date and should be completed by the physi- cal therapist. Often, these notes are required by state law or third-party payers to ensure that the physical therapist is maintaining patient care responsibility and meeting legal and ethical expectations. Discharge notes are written at the conclusion of an episode of care and summarize the physi- cal therapist care provided and the patient’s response.

The initial evaluation note provides a clear picture of the patient by including pertinent history, risk factors, and results of tests and measures. It also includes the physical therapist’s professional judgment about the patient’s condi- tion, including the diagnosis, prognosis, and anticipated goals. Finally, the evaluation note includes recommenda- tions and the physical therapist’s plan of care.

As a physical therapist assistant, you will use the physi- cal therapist’s initial evaluation note as a reference for each patient contact. The evaluation note should provide the framework upon which all patient-related activities you engage in are based. From the evaluation note, you should be able to obtain a clear picture of what is happen- ing with the patient and how physical therapy services will be administered to address the patient’s problems. You will have at least a general idea of what to anticipate when you

work with the patient. This includes times when your inter- action with the patient begins later in the patient’s episode of care. Even though the patient might have had several physical therapy sessions, it will be important for you to review the initial evaluation note to gain a clear picture of the plan of care established by the physical therapist. In addition, you will need to review any subsequent documen- tation (interim and re-evaluation notes) to gain an appreci- ation for how the patient has responded to the interventions and to see whether there have been any updates or revisions to the plan of care.

Let’s look at what a typical physical therapy evaluation note written in the SOAP (subjective, objective, assessment, and plan) note format looks like and discuss how you can utilize this information to determine what you will do with the patient. Remember, even if an evaluation note is not documented in the SOAP note format, any patient record should have the same types of information. We will use the SOAP note format as a learning tool to help you distinguish what information you need to attend to and how you need to process the information to assist in deciding how to pro- ceed with patient care activities. Once you learn the ques- tions that you need to ask when reviewing an evaluation note, you should be able to find the information that you need, regardless of the documentation format used.

SOAP INITIAL EVALUATION NOTE As you review a physical therapy evaluation note, you

will find information related to the examination in the problem, subjective, and objective sections. Evaluation information, including the diagnosis, prognosis, and goals, can be found in the assessment portion of the note. Finally, the plan for intervention will be documented primarily within the plan section (Table 7-1). We will look at each section individually, and then discuss how you will utilize the information to make decisions about what to do during your interactions with the patient.

Problem (Pr) As noted in Chapter 4, one adaptation to the standard

SOAP format is the addition of a problem section (Pr). When included, the problem section is the first part of the initial evaluation note and provides information about the patient’s reason for seeking physical therapy services. The following information may be found in this section:

• Patient’s chief complaint • Medical diagnosis • Contraindications or precautions • Physical therapy diagnosis • Referral for physical therapy services • Functional limitations • Information gleaned from the medical record

Interpreting the Physical Therapist Initial Evaluation 61

º Recent or past surgeries º Past conditions or diseases º Present conditions or diseases º Results of medical tests

In many settings, the problem section only includes the medical diagnosis and/or referral information with the remainder listed elsewhere (Example 7-1). When a problem (Pr) section is not included, the information can be found in other areas of the patient record. Sometimes, it is a direct statement prior to the remainder of the SOAP note, which provides the reason for referral or the patient’s reason for

seeking physical therapy services. These umbrella state- ments provide the context for the remainder of the initial evaluation note.

Subjective (S) The subjective section of a SOAP note provides all per-

tinent data obtained from the patient, the patient’s family, or other individuals familiar with the patient’s history. The subjective information is a component of the history-taking portion of the examination (Figure 7-1). The following information can be found in this section:

• Patient’s current and past medical history • Patient’s symptoms or complaints • Factors that cause the symptoms or complaints • Patient’s prior level of function • Patient’s lifestyle/occupation/societal roles • Patient’s goals

As you begin to review physical therapy documenta- tion in a variety of settings, you will find that information gleaned from the patient’s medical record can be recorded in a variety of areas. There is no standard regarding this practice. As noted previously, some information might be found in the problem or subjective areas of the note. Additionally, some settings will have a separate section labeled as “Medical History.” On occasion, the information is recorded in the objective section of the note. Regardless of where the information is documented, it is important for the physical therapist to indicate when the information was gleaned from a medical record instead of a patient’s self- report (Example 7-2).

Table 7-1 Where the Elements of the Patient/Client Management Model Can Be Found in a SOAP Note

Element of Patient/Client Management Model SOAP Initial Evaluation Note

Examination History

Problem Subjective

Systems Review Objective Tests and Measures Objective

Evaluation Assessment Diagnosis Assessment

Prognosis Assessment Plan

Intervention Plan

Example 7-1 Outpatient Physical Therapy Evaluation

Patient: S.S. Age: 32 y.o. Date of Eval: 7/14/16 Referral: PT to eval & tx Referring Physician: Dr. Mark Long Pr: ICD-10: G35 Multiple sclerosis—progressive

remitting type Impaired motor function and sensory integrity Balance and coordination deficits

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Example 7-2 Subjective Component of an Initial Evaluation

S: Demographics: 32-year-old right-handed Caucasian female; English speaking; completed 2 years of undergraduate college education. Social History: Pt. lives at home with her husband and 7-year-old son. Three steps with a railing to enter her one level home. Pt.’s husband works during the day and her son goes to school. Her husband has been taking time off from work to stay with her during the day, but will have to return to work this week. Pt. has various friends and family who have agreed to help during the day until she is safe to be alone at home. Pt. normally active with taking son to after-school activities. Employment Status: She is normally employed as a bank teller, but is unable to return to work at this time due to fatigue issues and “clumsiness.” General Health Status: Pt. reports prior to this last exacerbation that she was in good health. Her primary activities included work, home care, and tending to her son, who participated in a variety of after-school activities. Medical History: Pt. reports that she has not had any other issues that had required medical attention other than the birth of her son and typical illnesses (eg, colds, flu). Current Condition: Pt. states that she was diagnosed with progressive MS 2 years ago. On 7/1/17 she had an exacerbation of her MS that led her to be hospitalized for 3 days of IV anti-inflammatory medica- tions. She was discharged to home on 7/4/17 with a wheeled walker. She was receiving physical therapy while in the hospital. During her follow-up visit with her physician on 7/7/17 pt. requested more physical therapy due to balance and coordination problems. Pt. currently complains of “being unsteady on my feet,” and being “clumsy with everything.” Pt. reports that she will be receiving occupational therapy to address coordination problems that interfere with daily functioning. Functional Status: Pt. states that she was previously independent with all activities of daily living and gait without an assistive device, but has been using a wheeled walker with assistance at home and a wheelchair for limited trips outside of the home due to her unsteadiness. She reports having purchased the wheeled walker from a friend at church and borrowing the wheelchair from her mother-in-law. Pt.’s Goals: Pt. states that she would like to be able to walk without an assistive device, to return to work, and to be able to do housework.

Figure 7-1. The subjective section of a SOAP note. (Reprinted with permission from Erickson M, Utzman R. McKnight R. Physical Therapy Documentation: From Examination to Outcome. Thorofare, NJ: SLACK Incorporated; 2012.)

Subjective Information

Is a component of the history- taking portion of the

examination

The following types of informa- tion

Includes

Pertinent data

obtained from:

Patient Patient’s medical record

Patient’s family/ caregiver

Patient’s current and past medical history

Patient’s symptoms or complaints

Factors that impact the symptoms/complaints

Patient’s prior level of function

Patient’s lifestyle/occupation/societal roles

Patient’s goals

Interpreting the Physical Therapist Initial Evaluation 63

Objective (O) The objective section of a SOAP note includes infor-

mation gleaned during the examination via the systems review and through various test procedures, including the physical therapist’s observations. Tests performed may be more diagnostic in nature, such as musculoskeletal special tests, while other tests are more prognostic in nature, such as the Berg Balance Scale, which is utilized to determine a patient’s fall risk. Some tests are only appropriate for the initial evaluation, while others can be used to demonstrate the patient’s progress through repeated testing throughout the episode of care. Whenever possible, the therapist should utilize standardized tests to increase the validity and reli- ability of the measurements obtained. Objective data must have some measure of reliability to be useful in supporting clinical decision making. In the event that a standardized test must be modified due to patient or environmental limi- tations, the therapist should clearly document the modi- fications. In addition to examination observations and measurements from tests performed, the objective section will include documentation of any interventions provided as part of the visit when the examination occurred and the patient’s response to those interventions (Figure 7-2). Sidebar 2-2 in Chapter 2 lists the categories of tests and measures that can be found in the objective section of the evaluation note. As noted earlier, in addition to the data from tests, the objective section will include a category for interventions provided (Example 7-3).

Assessment (A) The assessment section of a SOAP note documents the

physical therapist’s evaluation. The American Physical Therapy Association’s Guidelines: Physical Therapy Documentation of Patient/Client Management describe evaluation as “a thought process”.1 As such, the “thought process” may not be directly documented; instead, the

physical therapist will document the conclusions of the thought process. The assessment section provides an opportunity for the physical therapist to assign clinical meaning or value (evaluation) to the data collected during the examination process (documented within the subjec- tive and objective sections of the note). The assessment section is the component of the SOAP note where the physical therapist makes a case for the need for physical therapy services by providing evidence that the services are reasonable and necessary and require the skill of a physi- cal therapist or physical therapist. When formulating the assessment section, the therapist will sometimes choose to include a problem list that summarizes the body structure, function impairments, activity limitations, and participa- tion restrictions. The following information may be found in the assessment section:

• Physical therapist’s interpretation of subjective and objective data (an overall summary of the patient)

• Goals • Identification of impairments in body structures and

functions • Identification of limitations in activities and

participation • The relationship between body structure and func-

tional impairments and limitations in activities and participation

• Physical therapy diagnosis • Prognosis/rehabilitation potential • Justification for goals/treatment plan • Explanation of any difficulties with obtaining subjec-

tive or objective data • Discussion of the patient’s other problems (medical,

social, financial) that can impact the patient’s physi- cal functioning or participation with a plan of care (comorbidities or complexities; Example 7-4)

Figure 7-2. The objective section of a SOAP note. (Reprinted with permission from Erickson M, Utzman R. McKnight R. Physical Therapy Documentation: From Examination to Outcome. Thorofare, NJ: SLACK Incorporated; 2012.)

A component of the examination process.

Data gathered through direct observation

Gathered through methods that are reproducible

Used as a refer- ence for assessing outcomes

is Objective information includes

Data collected during

Interventions provided

Systems Review

Tests and Measures

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Example 7-4 Assessment Component of Initial Evaluation

A: Pt.’s motor deficits, including balance, coordination, and strength deficits, prevent her from functioning independently. Pt. is unable to maintain her current employment and is not able to meet her roles as a wife and mother. Pt.’s rehab potential may be limited due to diagnosis of progressive remitting type MS. Pt.’s fatigue level will limit her participation, but, with continued efforts, pt. may be able to achieve her stated goals. Will provide a 2-week trial of physical therapy intervention to evaluate pt.’s ability to par- ticipate with physical therapy interventions and determine pt.’s potential for improvement.

Short-Term Goals: To be achieved after 2 weeks of physical therapy. 1. Independent and safe with all transfers, including supine to/from sit and sit to/from stand to allow pt. to

be independent at home. 2. Pt. will ambulate with wheeled walker and standby assist on level services and minimal assistance on

uneven surfaces and on stairs for walker placement and safety due to fall risk. 3. Increase general endurance so pt. can participate with 30 minutes of functional and therapeutic activi-

ties and improve independence with functional activities at home. 4. Increase strength ½ grade throughout extremities to meet the above functional goals. 5. Improve coordination of extremities to meet the above functional goals. 6. Increase balance: as evidenced by a Berg Balance Scale score of 30 to improve safety during functional

activities. Long-Term Goals: No long-term goals set at this time until potential has been assessed over the next 2 weeks

of therapy intervention.

Example 7-3 Objective Component of Initial Evaluation

O: Systems Review: Cardiovascular/Pulmonary System: Blood pressure: 120/78. Heart rate: 78 bpm. Respiratory Rate: 16. Integumentary System: Unimpaired; skin intact, normal pliability. Musculoskeletal System: Gross symme- try unimpaired. Gross ROM unimpaired. Gross strength impaired equally bilaterally UEs and LEs. Neuromuscular System: Mobility impaired. Motor function impaired. Balance impaired. Communication: Unimpaired. Cognition: Unimpaired. Tests and Measures and Observations: Sensation: Pt. displays diminished sharp/dull, proprioception, and kinesthesia in both lower extremities from knees down. Strength: Assessed via MMT: 4-/5 to 4+/5 throughout all 4 extremities utilizing standard test positions. Mobility: Independent with bed mobility, supine to/from sit and sit to/from stand requires standby assist to monitor pt. safety due to ataxia Pt. ambulated 200’ with wheeled walker and minimal assistance on level surfaces, demonstrating ataxia in the trunk and both legs. Balance: Berg Balance 25. Coordination: Pt. displays ataxia of all 4 extremities during functional tasks and during coordination tests, including finger-nose-finger and heel-shin tests. Endurance: Fair for the above activities. Pt. stops activity due to complaints of fatigue after 15 minutes. Heart rate at time of stopping 83; Blood pressure 122/80.

Interpreting the Physical Therapist Initial Evaluation 65

Physical therapist patient care goals should be estab- lished in conjunction with the patient and should focus on the patient’s functional abilities (at the level of patient activities and participation) rather than on the level of impairments in body structures and functions. When the therapist chooses to address body structure and function impairments, it is essential for him or her to document the connections between these impairments and the patient’s activity limitations and participation restrictions.

Plan (P) The plan section of a SOAP note provides the written

plan for physical therapy services and is part of the estab- lished plan of care. The following types of information may be found in the plan section:

• Plan for intervention activities, including the following: º Collaboration/communication with other health

care providers º Patient-related education º Procedural interventions

• Frequency and duration of therapy services • Treatment progression expectations • Suggestions for further testing, treatment, referrals, or

consultations • Plans for further assessment or reassessment • Equipment needs • Referral to other services • Anticipated discharge plans (Example 7-5)

The plan should clearly demonstrate the connection between the physical therapy interventions and the goals. When goals appropriately demonstrate the connection with the patient’s activity limitations and participation restric- tions, this provides a clear link between the patient’s prob- lems, the goal expectations, and the chosen interventions.

HOW TO USE THE PHYSICAL THERAPIST INITIAL EVALUATION NOTE

When you review the initial evaluation note, you will want to glean specific information from each section to assist in determining what you need to do. To accomplish this, you need to start with a clear understanding of your role as a physical therapist assistant. As described in Chapter 2, the physical therapist assistant’s role is to provide interven- tions as directed by the physical therapist and as outlined in the established plan of care. You will want to focus on asking questions of the evaluation note that will facilitate your ability to carry out your role efficiently. As such, the first question you should ask is, “What intervention(s) does the physical therapist want me to provide?” Answering this question first provides the appropriate context, allowing you to correctly process all other information found in the evaluation note, thus providing a proper foundation for all of the decisions you will make related to the provision of the interventions. To effectively provide the interventions, you will need to have a clear understanding of what the interventions are designed to address. Therefore, your next question should be, “What problem(s) is the intervention addressing?” For example, knowing that the physical thera- pist wants you to help a patient with therapeutic exercises does not give you enough information to help you deter- mine which therapeutic exercises you will need to provide or how they need to be structured. Are the therapeutic exercises intended to address a lack of muscle strength, a cardiovascular endurance issue, or a balance deficit? The answer to this question will significantly impact how you should proceed.

After these questions have been answered, the next pair of questions you should ask will help you to determine the approach that you will take when providing the directed interventions. These questions are, “What is the patient’s current status regarding impairments in body structures or functions, functional capabilities, and activity participa- tion?” and “What are the goals set by the physical therapist and patient regarding identified problems?”

Following these questions, you should ask, “What is the patient’s diagnosis?” “What is the patient’s prognosis?” “Are there any contraindications or precautions that I need to keep in mind as I work with this patient?” and “Are there any other special issues that I need to keep in mind as I work with this patient?” Special issues or considerations could include things such as the patient’s cognitive or psy- chological status. For example, it would be important to know whether the patient has a hearing or visual impair- ment to modify the therapy interventions to allow him or her to participate successfully in the therapy activities (Figure 7-3). The order of questions described in this sec- tion and as depicted in Figure 7-3 does not imply that one question is more important than the other. Rather, this sequence helps to ensure that the physical therapist assis-

Example 7-5 Plan Component of Initial Evaluation

P: Will be seen 3 times a week as an outpa- tient. Pt. will receive strengthening exer- cises, balance, and coordination activities, functional mobility training, and gait train- ing. Will continue gait training with wheeled walker until independent gait with wheeled walker is achieved, then will progress to gait training with other assistive device, as indi- cated. Will coordinate care provided with occupational therapist.

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tant is processing the information found within the evalua- tion note in a manner that will ensure efficient and effective clinical decision making.

Now that we have identified the questions that should guide your review of the initial documentation, let’s discuss where you will find this information within the note itself.

Question 1: “What intervention(s) does the physical thera- pist want me to provide?”

Although this question is often answered during a direct face-to-face conversation with the physical therapist, it is important for you to review the evaluation note to discover what it says as well. On occasion, the physical therapist might ask you to perform an intervention that is not includ- ed in the plan of care. In this case, it is your responsibility to clarify the need for the intervention with the physical thera- pist and to ask him or her to update the plan of care accord- ingly. In addition, the evaluation note provides details that the therapist might not remember to communicate that can help you to determine specific strategies to utilize during

patient care activities. On other occasions, you will need to determine which interventions to provide solely based on the evaluation note. To find this information, you should start by looking at the plan part of the note. In the plan section of the note, the physical therapist will have outlined the interventions to be provided. Intervention categories are listed in Chapter 2 Sidebar 2-2.

Question 2: “What problem(s) is the intervention address- ing?”

As noted above, this question is imperative to help you determine, in more detail, how you will proceed when providing the intervention(s). Ideally, you will find this information in the plan alongside the intervention. For example, the physical therapist might write, “Patient to receive therapeutic exercise to address strength deficits in the right quadriceps.” When this much detail is included in the plan, it is easier for you to determine how you will proceed. This level of detail helps you to quickly determine which exercises you will instruct the patient to perform. In some cases, the plan will not provide adequate informa- tion for you to determine specifically what the interven- tions are intended to address, or perhaps the patient has multiple areas of involvement that need to be addressed. For example, a therapist might write a broad intervention statement such as, “Patient to receive therapeutic exercises to address muscle strength and endurance issues.” In this case, you will have more work cut out for you in your review to determine what muscles need strengthening.

Besides the plan section of the SOAP note, you can also find information in the assessment section (within the problem list and the goals) to help determine what problem(s) the interventions are designed to address. If, after a review of the evaluation note, you are still unclear of the purpose for the interventions, it is essential that you seek clarification from the physical therapist. Many interventions have the capacity to address more than one problem by utilizing different parameters. For example, electrotherapeutic modalities can address both pain and muscular weakness. A patient recovering from knee sur- gery could be dealing with both issues. If the therapist indicated the use of electrotherapeutic modalities in the plan but did not specify which problem the intervention is designed to address, you would need to clarify this prior to utilizing the modality.

When the interventions being provided focus on the level of a body structure or function impairment, it is important that you consider how these impairments impact the patient’s activities and participation. Doing this ensures that you modify the intervention to address these func- tional issues. For example, a plan indicates that the patient is to receive strengthening exercises for weakened left knee musculature. Noting that the patient is demonstrating dif- ficulty with going up and down stairs due to the muscle weakness can guide you to decide to focus on closed chain exercises, which more directly translate into meeting the patient’s functional needs and personal goals.

Figure 7-3. Physical therapist assistant questions for the physical thera- pist evaluation note.

Questions the physical therapist assistant should ask during review of the evaluation note to ensure desirable clinical decisions are made:

What intervention(s) does the physical therapist want me to provide?

What problem(s) is/are the intervention addressing?

What is the patient’s current status regard- ing this condition?

What are the physical therapist’s and patient’s

goals regarding this condition?

What is the patient’s diagnosis?

What is the patient’s prognosis?

Are there any other special issues I need to keep in mind as I work with this patient?

Are there any contraindications or precautions I need to keep in mind as I work with this patient?

First question

Closely followed by

Interpreting the Physical Therapist Initial Evaluation 67

Questions 3 and 4: “What is the patient’s current status regarding impairments in body structures or functions, func- tional capabilities, and activity participation?” and “What are the goals set by the physical therapist and patient regard- ing identified problems?”

Information regarding the patient’s current status should be reviewed considering the established goals. This will help you to get an understanding of exactly what you should expect from the patient and how you should be prepared to progress with the patient. This will also provide you with a clear expectation of how quickly the physical therapist expects the patient to progress. Information regarding the patient’s current status can be found in the objective por- tion of the note. Further insights regarding the patient’s current status can be gleaned from the problem list and the narrative, or summary statement, found in the assess- ment portion. Goals established by the physical therapist are listed in the assessment section of the note with clearly detailed expected timelines for reaching the goals. As noted previously, you should make sure that you identify the functional goals or the connection between impairment goals and functional activities to ensure that you make sound decisions related to the implementation of interven- tions. In addition, it is important to cue into statements of patient desires or goals. Helping the patient to see how the activities and interventions being performed are addressing their personal goals can help to increase the patient’s moti- vation and participation with therapy.

Questions 5 and 6: “What is the patient’s diagnosis?” and “What is the patient’s prognosis?”

When looking at the evaluation note to find the patient’s diagnosis, you should remember to look for both the medi- cal diagnosis (eg, cerebrovascular accident [CVA], multiple sclerosis [MS], patella fracture) and the physical therapy diagnosis. The physical therapy diagnosis is often a state- ment that relates impairments to function (eg, decreased left lower-extremity strength resulting in limitations in self-care activities). The medical diagnosis may also be found in the problem section of the note. The physical therapy diagnosis will, at times, be found in the problem section as well, but it should always be found within the assessment component of the note.

The prognosis should be found as a direct statement within the assessment section of the note. The prognosis will also be communicated by the goals and time frame in which the goals are to be met. This information will provide you with a general idea of what to expect from the patient. For example, in the patient case above, as soon as Sarah read that S.S. has a diagnosis of progressive remitting MS, she had a general idea of what to expect from the patient based on her knowledge of that disease process. Further information provided in the remainder of the note helped Sarah to fill in the details so that she had a clearer picture of what to expect of S.S.’s status and performance.

Questions 7 and 8: “Are there any contraindications or precautions that I need to keep in mind as I work with this

patient?” and “Are there any other special issues that I need to keep in mind as I work with this patient?”

It is imperative for you to recognize and follow any con- traindications and precautions. Often, these will be directed by the physician, especially when related to recovery after a surgical procedure. When a contraindication is directed by the physician, it frequently is found within the problem component of the note. Additional precautions and contra- indications might be found within the assessment or plan sections of the note. At times, contraindications and pre- cautions are not directly specified, but rather it is expected that you will know the standard contraindications or pre- cautions associated with conditions commonly addressed with physical therapy services. For example, a patient who is recovering from a CVA has diminished muscle perfor- mance in the musculature surrounding the shoulder joint. It is expected that you will know the appropriate precau- tions to take to limit subluxation and potential dislocation of the joint. Therefore, when reading all components of the evaluation note, you will want to ask yourself whether there is any information that indicates specific contraindications or precautions that you need to monitor during provision of the directed interventions.

There are numerous additional issues that you might need to consider, and it is impossible to delineate all of them. The following examples demonstrate a couple of types of issues that you would need to consider:

• Upon review of the problem and subjective areas, you might find information regarding comorbidities that can impact the patient’s ability to participate in the interventions that you have been directed to provide. For example, you might be asked to provide transfer training for a patient who has left-side weakness due to a recent stroke. The chart indicates that the patient has previously had a right transtibial amputation. This information will help you to adjust your plan of action when deciding how you will approach the transfer training activities.

• Psychological and emotional issues might be recorded in the therapist’s note, providing you with valuable insight into specific strategies to utilize to optimize the care provided. For example, elderly individuals who have sustained injuries due to a fall incident often deal with issues related to fear of falling that can signifi- cantly impact their ability to participate and progress in physical therapy.

Because there is such a myriad of issues that can impact the provision of physical therapy, you will want to review the evaluation note for any potential issues so that you can modify the intervention strategy or your approach to increase the likelihood for success.

ADDITIONAL QUESTIONS TO ANSWER Once you have answered the above questions, you

should have a good idea of how you will proceed while

Chapter 7

working with the patient; however, there are a few more questions that you will want to ask prior to initiating the therapy session. After you have a clear picture of what inter- ventions you will provide and how you will provide them, you will want to ask which tests need to be performed prior to initiating the interventions. Measurements are gathered prior to beginning the interventions for 2 reasons. First, you will want to ensure that the patient’s status indicates that he or she is safe to participate in the specific interventions that you have been directed to provide. Second, you will want to gather any data essential to demonstrate the patient’s response to the intervention being provided.

“What tests do I need to perform prior to initiating inter- ventions to ensure that the patient is safe and able to partici- pate in the selected intervention(s)?”

Two pieces of data that should be collected prior to initi- ating any therapy session are heart rate and blood pressure. These data provide insight into the patient’s physiologic status and ability to safely participate in physical therapy interventions. As you review the evaluation note, you need to identify whether the patient has a history of a cardiovas- cular condition or is taking any medications that can alter normal cardiovascular responses. This will help you to be prepared to respond appropriately once you have gathered the patient’s heart rate and blood pressure readings.

Other data might be important to gather to determine the patient’s readiness to participate in the therapy session. This will be dependent upon the individual patient case. Examples include oxygenation saturation for individuals with a respiratory condition, pain ratings for individuals recovering from a musculoskeletal surgical procedure, and cognitive status for patients who have sustained a head injury due to trauma. Again, many other conditions exist that might require you to perform preintervention tests to determine the patient’s ability to participate in the inter- ventions. You will need to review the evaluation note to determine which tests that you will need to perform, obser- vations that you need to make, or questions that you need to ask of the patient.

“What additional tests do I need to perform to demon- strate the patient’s response to the intervention(s) provided and the patient’s progress toward the established goals?”

Other tests you might need to perform prior to initiating the intervention include tests that provide data regarding the patient’s response to the intervention(s). Sometimes this requires pre- and postmeasurements. Just as it is important to measure heart rate and blood pressure to ensure that it is safe for the patient to participate in physical therapy, baseline data are equally important to compare pre-, dur- ing, and postintervention measurements. For example, when documenting the patient’s cardiovascular response to therapeutic activities, heart rate and blood pressure measurements are the best method. Pain ratings are also commonly utilized to determine the patient’s response to the interventions during and after they are provided. Some interventions are directed toward pain management, and

the patient’s pain ratings pre- and postintervention are needed to demonstrate the effectiveness of the intervention. At other times, pain ratings are utilized to determine what the intensity of the intervention should be. The type of data needed depends upon the particular interventions being provided, the reason for the intervention, the goals, and the time frame in which goals are expected to be accomplished. You can speak to the physical therapist if you are unsure about how to gauge intervention intensity.

As you determine which tests you should perform, you will need to make a mental list of the equipment that you will need (eg, blood pressure cuff, stethoscope). In addition, as you review the subjective information, you will want to think about what questions you might want to ask the patient. In S.S.’s case, Sarah may want to ask how the assis- tance from friends and family has been working out.

Some tests and measures are necessary to provide information regarding the patient’s immediate response to interventions and are therefore performed pre- and pos- tintervention (and sometimes during). In other cases, tests and measures provide a longer-term view of the patient’s response to interventions and progress toward stated goals. As indicated earlier, heart rate and blood pressure mea- surements provide an immediate feedback regarding the patient’s cardiovascular response to a particular interven- tion. An example of measurements that provide a longer- term view of the patient’s progress includes measurements of muscle strength. In the case of S.S., to monitor the patient’s progress toward the established goals and respons- es to the interventions provided, Sarah will observe S.S.’s functional mobility status and then will need to perform manual muscle testing (MMT) and balance and coordina- tion testing as indicated by the time frame in the goals.

“What equipment will I need to be able to provide the intervention(s)?”

A review of the objective and assessment portions of the note will help you to determine what equipment you will need to provide the intervention(s). For example, upon review of S.S.’s evaluation note, you know that, to provide gait training activities, you will want to ensure that there is a wheeled walker and gait belt available.

“What other information should I keep in mind?” When reading the subjective portion of the note, you

also want to think about other pieces of information that you should be listening for as you provide your interven- tion. Frequently, patients share important information days or weeks after the initial evaluation that they forgot about at the time. This information can be useful in providing a more efficient plan of care. For example, if S.S. were to share a history of a previous right arthroscopic knee surgery with occasional knee pain, Sarah would want to document this information in the patient’s chart and communicate it to the supervising physical therapist. This may help to explain discrepancies in strength gains between the legs if any are noticed in future sessions.

Interpreting the Physical Therapist Initial Evaluation 69

When you review the objective information, you want to picture in your mind how the patient will look and act. This will allow you to anticipate appropriate responses to therapeutic intervention and will help you to identify inappropriate responses. As Sarah works with S.S., she will expect the patient to fatigue and will build rest breaks into the therapy session, depending upon the level of activities performed; however, Sarah will not expect any specific complaints of pain. If, for example, S.S. begins complain- ing of localized pain in her left ankle, Sarah would know to consult with the physical therapist.

As you read the assessment portion of the note, you will be able to mentally outline how the patient should progress. This will guide you in the day-to-day decisions about what needs to happen with the patient. A review of the plan sec- tion will tell you the anticipated duration of the episode of care. Based upon John’s assessment of S.S., Sarah would not be alarmed if the patient did not show significant improve- ments over the course of the treatment plan.

“Do I need to know anything else?” The final question that you need to ask yourself is, “Is

there any other information that I need that is not found in the evaluation note?” If the answer is yes, then you will want to seek out the information from the appropriate source, and that source may or may not be the physical therapist. For example, you know that the patient had labo- ratory work done earlier in the day. You will want to review the laboratory values to determine whether it is safe for the patient to participate in therapy or whether the physical

therapist needs to be contacted. It is imperative that you ask clarifying questions prior to initiating care to ensure the safety of the patient and to improve the effectiveness of care. If the patient’s initiating therapist is not available, you should ask the therapist providing supervision and direc- tion for the patient on that day.

At this point, it should be clear how important the evalu- ation note is in providing essential information to guide the physical therapist assistant’s decision-making process regarding interventions. In addition to providing informa- tion that helps the physical therapist assistant to proceed with patient care, the evaluation note provides a clue as to what the interim note should include. Over the next three chapters we will look at each part of a SOAP note and dis- cuss how to compile an interim note that shows clear con- nections with the initial evaluation.

REFERENCES 1. American Physical Therapy Association. Guidelines:

Physical Therapy Documentation of Patient/Client Management. BOD G03-05-16-41. https://www.apta.org/ uploadedFiles/APTAorg/About_Us/Policies/BOD/Practice/ DocumentationPatientClientMgmt.pdf. Updated December 14, 2009. Accessed July 11, 2017.

2. American Physical Therapy Association. Guide to Physical Therapist Practice 3.0. APTA website. http://guidetoptprac- tice.apta.org/content/1/SEC2.body. Updated August 1, 2014. Accessed October 24, 2016.

Chapter 7

APPLICATION EXERCISES I. Using the case examples provided in Examples 7-6 through 7-8, practice reviewing initial evaluation notes to pre-

pare for a treatment session. Utilize the following questions outlined in this chapter:

1. What intervention(s) does the physical therapist want me to provide?

2. What problem(s) are the intervention addressing?

3. What is the patient’s current status regarding impairments in body structures or functions, functional capabili- ties, and activity participation?

4. What are the goals set by the physical therapist and patient regarding identified problems?

5. What is the patient’s diagnosis?

6. What is the patient’s prognosis?

7. Are there any contraindications or precautions that I need to keep in mind as I work with this patient?

8. Are there any other special issues that I need to keep in mind as I work with this patient?

9. What tests do I need to perform prior to initiating interventions to ensure that the patient is safe and able to par- ticipate in the selected intervention(s)?

10. What additional tests do I need to perform to demonstrate the patient’s response to the intervention(s) provided and the patient’s progress toward the established goals?

11. What equipment will I need to be able to provide the intervention(s)?

12. What other information should I keep in mind?

13. Do I need to know anything else?

Interpreting the Physical Therapist Initial Evaluation 71

Example 7-6 Anytown Community Hospital: Skilled Nursing Facility

Physical Therapy Evaluation Patient: J.M. Age: 76 y.o. Date: 04/04/17 Referral: Physical therapy for gait and strengthening. Anterior hip precautions. Weight-bearing as tolerated. Referring Physician: Dr. Mark John Pr: Left total hip arthrpolasty 03/30/17. Hypertension; 2 previous TIAs approximately 1 year ago. S: Complaint: Pt. states that he does have some soreness, but, in general, his hip pain is less than before the

surgery; rates pain as 1–2/10 and states that it hurts worse at the end of the day. Living Environment/Social Support: Pt. reports that he lives at home with his wife. His wife is generally in good health and is active in the community, but pt. is concerned about being a “burden” on his wife when he returns home. Pt. states that he has 3 steps with railing on 1 side to enter his one level home. Prior Level of Function/Activities: Pt. states that he was previously independent with activities of daily liv- ing and gait without an assistive device; his hobbies include yard work and doing crossword puzzles; he is retired. Pt. normally attended church twice a week and met with friends for coffee 3-4 times a week. Pt. enjoys fly fishing 3-4 times a month “depending upon the weather.” Pt. Goals: Pt. states that he would like to return to his previous level of activity and specifically is hoping to participate in a fishing tournament this fall.

O: Systems Review Cardiovascular/Pulmonary System: Unimpaired. BP: 130/85. HR: 88 bpm. RR: 20. Integumentary System: Healing scar left hip, staples intact, no drainage noted. Musculoskeletal System: Gross strength general decrease bilateral UEs and right lower extremity; left lower extremity impaired due to recent surgery. Gross range of motion left lower extremity restricted due to orthopedic precautions; other extremities and trunk unimpaired. Neuromuscular System: Balance and motor control unimpaired. Functional mobility impaired. Communication: Unimpaired. Cognition: Unimpaired. Tests and Measures and Observation Strength: 4/5 to 4+/5 throughout bilateral upper extremities and right lower extremity. Left hip mus- culature not tested at this time due to recent surgery. Appears 2/5 with functional mobility. Left knee strength 3+/5, ankle strength 5/5. Mobility: Scooting in bed minimal assistance to assist left lower extremity. Supine to/from sit with mod- erate assistance of 1, Sit to/from stand with minimal assistance of 1. Gait: Pt. ambulated 50’ with walker and minimal assistance of one, weightbearing as tolerated left lower extremity. Pt. needed frequent verbal cues for proper walker placement due to tendency to place walker too far in front of him. Intervention: Initiated bed mobility training, transfer training, and gait training using front wheeled walk- er; active assistive range of motion to left lower extremity, including ankle pumps, quad sets, ham sets, glut sets, short arc quads, straight leg raise, hip abduction, and heel slides 2 x 10. Pt. required minimal assistance of 1 with short arc quads and heel slides and moderate assistance of 1 with straight leg raises and hip abduction. Pt. Education: Pt. was instructed in hip precautions. Pt. was able to repeat hip precautions after 10 minutes of alternate activities.

(Continued)

Chapter 7

Example 7-6 (Continued) A: Pt.’s decreased strength left lower extremity is limiting his functional independence. Pt. is unable to

return home at this time due to dependence with mobility and need to learn hip precautions to protect recent total hip arthroplasty. This pt. is very motivated and does not have significant comorbidities and therefore has excellent rehab potential.

Problem List 1. Decreased strength left lower extremity 2. Dependent mobility 3. Dependent gait 4. Does not know hip precautions for functional tasks Short-Term Goals: To be met within 2 days 1. Pt. will require standby to contact guard assist with all bed mobility and transfers. 2. Pt. will ambulate 100’ with walker and contact guard assist on level surfaces. 3. Increase left lower-extremity strength to 3/5 throughout hip and 4-/5 knee to be able to meet the above

functional goals. 4. Pt. will be able to verbalize all hip precautions and will demonstrate understanding of precautions dur-

ing basic transfers and gait activities. Long-Term Goals: To be met within 7 days to allow pt. to return home with his wife. 1. Pt. will be independent with all bed mobility and transfers and car transfers with minimal assistanceof

wife. 2. Pt. will ambulate 200’ with walker independently on level surface and up and down 3 steps utilizing rail-

ing on one side with standby assistance of wife. 3. Increase left lower-extremity strength to 3+/5 throughout hip and 4/5 knee to be able to meet the

above functional goals. 4. Pt. will display good understanding of hip precautions during all functional activities, including car

transfers and gait on stairs. P: Physical therapy twice a day for ROM/strengthening exercises, transfer training including car transfers,

gait training including gait on stairs and education regarding hip precautions with all functional tasks. Ted Orlando, DPT

Interpreting the Physical Therapist Initial Evaluation 73

Example 7-7 Anytown Community Hospital: Subacute Rehabilitation

Physical Therapy Evaluation Patient: I.H. Pt.: Age: 68 y.o. Date: 05/26/17 Referral: Physical therapy to evaluate and treat as advised. Referring Physician: Dr. Sue Morton Pr: Brainstem CVA 05/21/17, type 2 diabetes, right carotid endarterectomy 07/10, and 3 previous TIAs. S: Current Condition: Pt. reports that on 05/21/17 she awoke to find that she could not get herself out of

bed. She had been experiencing feelings of fatigue and weakness the evening before and had gone to bed early. Her husband called emergency services and she was transported to the hospital where the diagnosis of brainstem CVA was made. Pt. Complaint: Pt. complains of weakness on the right side of her body and “clumsiness” with her left arm. She states she is unable to anything on her own at this point. Pt. admits to being very frustrated and just “wants to give up.” Living Environment/Social Support: Pt. reports she previously lived at home with her husband in a one- story ranch style home with one step to enter. Pt. and her husband have 3 children. One son lives in the area and can be available to assist some. The other 2 children do not live in the area. Her husband owns his own business as an electrician and will be able to cut back his “hours of work” to help her if needed. Prior Level of Function/Activities: Pt. states she has always been a “housewife” and is sure that her husband would be unable to “run the home.” Social activities include being involved in a reading club that meets monthly and going to church weekly. Pt. also reports that she occasionally keeps her neighbor’s children in the evenings. The children are 5 and 8 years old. Pt.’s Goals: She states she and her husband are hoping that she can eventually return home. She would like to return to as many of her previous activities as possible but voices she understands she may need to use a cane, walker, or wheelchair to get around. She is most concerned about being able to take care of her home including doing dishes, laundry, and general house cleaning tasks.

O: Systems Review Cardiovascular/Pulmonary System: BP: 128/70. HR: 74 bpm. RR: 20 Integumentary System: Unimpaired. Musculoskeletal System: Gross ROM unimpaired. Gross strength impaired throughout trunk and bilateral upper extremities and lower extremities right greater than left. Neuromuscular System: Balance and motor control impaired throughout trunk and all 4 extremities. Functional mobility impaired for all tasks. Communication: Mild slurred speech. Pt. is easily understood. Cognition: Unimpaired. Other: Urinary catheter noted.

(Continued)

Chapter 7

Example 7-7 (Continued) Tests and Measures and Observation

Observation: Pt. grossly obese. Sensory: Pt. demonstrates normal light and gross touch, pain/thermal and diminished proprioception/ kinesthesia on left and mildly diminished light and gross touch, pain/thermal, and proprioception kinesthesia on right throughout trunk and extremities. Tone: Pt. displayed mild hypotonia right upper and lower extremity and normal tone left upper and lower extremity. Coordination: Unable to assess right side due to weakness. Left upper and lower extremities demonstrate diminished coordination with all activities. Note apraxia and pass pointing during exercises. Bed Mobility: Maximum assistance of 1 with rolling and scooting in bed. Transfers: Maximum assistance of 1 supine to/from sit. Unable to perform sit to/from stand at this time. Bed to/from mat at this time is via Hoyer due to pt.’s large size, poor balance, and weakness.

MMT Right Left

Shoulder

Flexors 2/5 4/5

Extensors 1/5 4/5

Abductors 1/5 4/5

Adductors 2/5 5/5

Medial rotators 2/5 5/5

Lateral rotators 1/5 4-/5

Elbow

Flexors 2/5 5/5

Extensors 0/5 4+/5

Wrist

Flexors 1/5 4/5

Extensors 0/5 4-/5

Grip 5# 28#

Hip

Flexors 1/5 4-/5

Extensors 3/5 4-/5

Abductors 0/5 4-/5

Adductors 3+/5 5/5

Knee

Flexors 0/5 4/5

Extensors 2+/5 5/5

Ankle

Dorsiflexors 0/5 4+/5

Plantarflexors 1/5 5/5

(Continued)

Interpreting the Physical Therapist Initial Evaluation 75

Example 7-7 (Continued) A: This obese pt. has very severe functional disabilities. Pt. is motivated and pleasant to work with. Due to

the severe deficits, prognosis for significant recovery is poor; however, pt. and her husband want to try to get her back home. A trial of structured aggressive therapy is indicated to see how much functional return is possible for this pt. and to educate her husband on how to provide any necessary care.

Problem List 1. Decreased strength right greater than left 2. Decreased coordination left upper and lower extremities 3. Decreased balance 4. Dependent with all mobility Short-Term Goals: Within 2 weeks pt. will display the following: 1. Moderate assist of 1 for bed mobility and supine to/from sit. 2. Maximum assist of 1 for bed to/from wheelchair using slideboard transfer. 3. Fair static and fair− dynamic sitting balance to allow for slideboard transfer goal. 4. Increase strength ½ grade throughout to be able to achieve functional goals. 5. Improve coordination left upper and lower extremity to be able to achieve functional goals. Long-Term Goals: Within 4 weeks, pt. will display the following: 1. Minimal assistance of 1 for bed mobility and supine to/from sit. 2. Moderate assistance of 1 for bed to/from wheelchair using slideboard transfer. 3. Fair+ static and fair dynamic sitting balance to allow for transfer goals. 4. Increase strength 1 grade throughout to be able to achieve functional goals. 5. Improve coordination left upper and lower extremities to be able to achieve functional goals. 6. Pt.’s husband will safely assist her with bed mobility and all transfers. P: Physical therapy twice a day for neuromuscular re-education, strengthening exercises, endurance activi-

ties, mobility training, and family education. Will assess pt.’s equipment needs for home use and facility acquisition of the equipment. Pt. will require, at minimum, a wheelchair and a bedside commode. Prior to discharge, recommend that pt. and her husband stay in the independent apartment to assess their ability to manage in a “home-like” environment. Anticipate continued therapy through home health ser- vices will be needed. If pt. demonstrates good recovery over her rehabilitation stay, may recommend an extension of her stay to work toward greater independence.

Joe Jackson, DPT

Chapter 7

Example 7-8 Anytown Community Hospital: Outpatient Rehabilitation Services

Physical Therapy Evaluation Patient: B.H. Age: 85 y.o. Date: 09/26/17 Referral: PT for ROM and strengthening to the (L) elbow. Referring Physician: Dr. Jeff Gordon Pr: (L) Elbow fracture s/p ORIF 8/18/17; (L) hip fx s/p ORIF 1/15 S: Current Condition: Pt. states that she broke her arm when she missed a step coming out of her house into

her garage 08/18/10; pt.’s husband took her to the emergency department; she had surgery the same day and returned home the next day. During a follow-up visit to the doctor on 09/21/17, the cast was removed. Pt. states that she is coming to the PT to get her “arm working again.” Patient Complaint: Pt. reports that her (L) UE seems to ache all the time especially over the weekend since her cast was removed. Pt. ranks her pain as 2/10 at rest, 3–4/10 with activities, 6–7/10 during stretching/ROM exercises. Pt. reports that she still is occasionally using painkillers prescribed by the phy- sician and reports relief of her pain with medications. Living Environment/Social Support: Pt. lives at home with spouse. Denies any steps to negotiate. Pt. reports prior to accident she was (I) with ADLs and gait without (A) device. Pt. does own a walker from previous (L) LE surgery; pt. reports she has needed assistance with self-care and ADLs such as bathing and dressing due to pain and stiffness since her surgery. Pt. and spouse both retired. Pt. states that she likes to garden. Pt. is (R) hand dominant. Patient Goals: Pt. states she wants to return to her normal function.

O: Palpation: There is generalized soreness upon palpation of the entire (L) elbow region. Pt. also displays tenderness in the (L) brachioradialis muscle. Inspection: Pt. displays a well-healed incision on the elbow. ROM: (B) Shoulder AROM WNLs throughout

(R) (L) PROM elbow extension/flexion 0° to 150° 90° to 130° Forearm supination 90° 45° Forearm pronation 90° 35° Wrist flexion 75° 0° Wrist extension 80° 45°

Pt. is unable to make a complete fist with the (L) hand due to discomfort and “stiffness.” Formal mea- surements of finger joints not performed this date due to pt. needing to get to a personal function. To be deferred to next session. Strength: (R) UE 4+/5 to 5/5 throughout all musculature. (L) shoulder 4-/5, (L) elbow pt. unable to tolerate any resistance; does perform against gravity showing 3-/5 of biceps and triceps. Grip strength (R) 40#, (L) 25#. Intervention: pt. received MHP x 20 mins to (L) elbow and (L) hand. Gentle stretching and mobilization to elbow joints followed this. PT performed AAROM to (L) elbow, wrist and hand 10 repetitions. Patient Education: Pt. was instructed in gentle self ROM techniques. Pt. was issued a written HEP of these ROM activities (see copy in pt. chart). Pt. was advised to use prescription pain medication approximately 30 minutes before the next therapy session to increase tolerance to the activities.

(Continued)

Interpreting the Physical Therapist Initial Evaluation 77

Example 7-8 (Continued) A: Pt. displays limited ROM, decreased strength, and (L) hand edema, which are impeding her functional

tasks at home. Pt. had an increase in pain to 6–7/10 during therapeutic ROM and stretching. STGs: To be achieved within 5 treatment sessions. All impairment goals listed are to facilitate pt. to be able to be (I) with self-care activities. 1. Decrease edema in the (L) hand to equal the (R) 2. Increase (L) wrist ROM to WNL 3. Increase elbow flexion to 140° and extension to 0° LTGs: To be achieved within 14 treatment sessions. All impairment goals listed are to facilitate pt. to be able to return to normal activities including house work and gardening. 1. Increase strength in the (L) elbow and hand to 4/5 to 4+/5 throughout to allow increased functional

activities 2. Increase (L) elbow ROM to WNL to allow normal eating and self-care 3. Pt. will be (I) with basic ADLs and IADLs P: Pt. to receive physical therapy 3x/week for modalities, ROM, and progressive therapeutic exercises to

the (L) elbow, wrist, and hand. Will include general ROM and strengthening exercises to the shoulder to minimize effects of decreased activity on that musculature/joint.

Stephanie Wright, DPT

Chapter 7

REVIEW QUESTIONS 1. For each of the following components of the Patient/Client Management Model, indicate where this information

can be found within an initial evaluation note written in the SOAP note format. Write Pr for problem, S for sub- jective, O for objective, A for assessment, and P for plan.

Prognosis Examination: History-taking Evaluation Intervention Examination: Systems review Diagnosis Examination: Tests and measures

2. For each of the following types of information that may be found in a physical therapy evaluation note, indicate where the information would be documented in the SOAP note format. Write Pr for problem, S for subjective, O for objective, A for assessment, and P for plan.

Rehabilitation potential Patient education provided Medical diagnosis Patient’s complaints Equipment needed Goals Recent surgeries Patient’s prior level of function Interventions provided Results of tests

3. Why is it important to document patient education and communication within the intervention provided in the Patient/Client Management Model?

4. What are some questions that the physical therapist assistant should ask when reviewing the evaluation note to guide interventions?

5. Discuss the importance of starting the review of the evaluation note by determining what interventions the physical therapist wants you to provide.

Rebecca McKnight, PT, MS

Erickson ML, McKnight R. Documentation Basics for the Physical Therapist Assistant, Third Edition (pp. 79-85)

Writing the Subjective Section

Chapter 8

After reading this chapter, the reader will be able to do the following: 1. List sources of information for subjective (history)

data. 2. Identify types of data that should be recorded in the

subjective portion of a SOAP (subjective, objective, assessment, and plan) note.

3. Discuss how subjective data are used to inform the clinical decision-making process.

4. List types of information that should be recorded in the subjection section of the interim note.

5. Describe the importance of linking subjective infor- mation in the interim note with information in the evaluation note.

Subjective data is information that the physical therapist assistant gleans from other individuals rather than data gathered through direct observation. In general terms, subjective means from the perspective of the subject or individual. As such, something is subjective when it includes the thoughts, perspectives, and emotions of the individual. The subjective section of a SOAP note contains

both subjective information and simple statements of fact. For example, a patient’s report of the date of his or her surgery, a nurse’s report of the patient’s temperature, or laboratory report finding are all information that are not filtered through a personal perspective. What makes infor- mation “subjective” for documentation in the SOAP note is not the type of information (personal perspective vs fact based), but rather the source of the information. When you include information in the subjective portion of the SOAP note, you are indicating that you obtained the information from somewhere else and did not collect the data or observe the facts yourself.

As stated, some of the information documented in the subjective section will be from a personal perspective. For example, a patient may make a statement about the impact of a condition on his or her emotional status. You might feel that information from a personal perspective is not as valu- able as fact-based information; however, it is important to remember when working with people that understanding their personal perspective can be a valuable way of getting a holistic view of the person. A patient’s perspective and emotions can have significant bearing on how he or she will respond to therapeutic activities, which can impact his or her progress. In this chapter, we focus on identifying the

CHAPTER OBJECTIVES

KEY TERMS Informed consent | SOAP note | Subjective data

KEY ABBREVIATIONS SOAP

Chapter 8

types of data that you will need to consider including in the subjective component of an interim note. Most of the time, the data will be more fact-based information. You should, however, endeavor to include patient or patient family/ caregiver statements that provide insight into the patient’s psychological and emotional perspective.

WHERE DOES IT COME FROM? In most cases, subjective information is data gathered

from the patient through direct and specific questioning. Individuals who are in close relationships with the patient may also be able to provide direct information about the patient’s condition and functional status. The patient’s family or caregiver can provide additional information and alternate perspectives that can help form a more com- prehensive view of the patient’s status. In cases where the patient has cognitive or communicative limitations and where no medical records exist, the subjective information may come entirely from the family or caregiver. In these situations, the physical therapist assistant should identify the individual who has the closest contact with the patient. This person will likely be the individual who can provide the clearest picture of the patient’s functional abilities and limitations.

WHAT DOES IT INCLUDE? The subjective section of the SOAP note answers the

question, “What does the patient (or the patient’s family member/caregiver) have to say?” The subjective informa- tion provides the patient’s perspective and documents valuable information to support the effectiveness of the treatment plan or to demonstrate the need for an altera- tion of the treatment plan. Subjective information includes data that provides insight into the patient’s condition and its impact on the patient’s functional mobility and activ- ity participation. The physical therapist assistant should remain alert to patient and caregiver comments related to the impairments in body functions, functional limitations, and activity restrictions associated with the current condi- tion. This information will also help the physical therapist assistant discern the patient’s emotional response to these issues and will allow the physical therapist assistant to respond appropriately or modify the intervention strate- gies, as necessary. Specific statements, which provide a view into the patient’s perspective and functional status, should be quoted within the interim note. Subjective information can provide a view into the psychosocial issues and con- textual factors that influence the patient’s functioning and participation.

When writing the subjective section, you should docu- ment any comments from the patient or the patient’s family member(s), caregiver(s), or significant other(s) that dem- onstrate the following: (1) the patient’s status/progress, (2)

the patient’s reaction to interventions provided, or (3) new problems, new complaints, or any pertinent information not previously documented. The physical therapist assistant should work to include information that provides a clear picture of how the patient is functioning.

In addition to the patient and patient’s family/caregiver, a physical therapist assistant may get information about the patient from other health care providers or from a medical record. Data gathered from these sources can be recorded in several areas of the SOAP note. Regardless of where the information is documented, it is essential that the physical therapist assistant identifies the source of the information. For the purposes of the examples in this text, we record information gleaned from the medical record or received from other health care providers (eg, occupational thera- pist, orthotist, nurse) in the subjective component of the note. Brief, fact-based data, such as laboratory and radio- logic findings, might also be documented in the problem section.

As described in Chapter 7, the initial evaluation should be a tool that you use to determine questions that you should be prepared to ask during a therapy session. As you review the initial evaluation, interim notes, and any re- evaluations, you should identify subjective data to gather that can demonstrate the patient’s progress. Example 7-2 lists types of subjective information that can be found in an initial evaluation note. Two of the categories of information do not change and therefore do not need to be addressed or included in an interim note. These include general demographics and growth and development. Three of the categories contain information that is unlikely to change; however, sometimes information that the patient forgot to mention during the initial evaluation may surface in subsequent sessions or new information may surface. This includes information about the patient’s medical/surgical history, family history, medications, and other clinical tests. If the patient shares information not noted in the physical therapist evaluation, you should document the informa- tion and contact the physical therapist. Likewise, you will want to document and inform the physical therapist of any new clinical test data that have the potential to impact the patient’s ability to participate or progress in therapy. In the areas of social/health habits, social history, living environ- ment, and general health status, you should note whether the physical therapist indicates a concern or issue; if so, you should be prepared to ask the patient follow-up questions related to the issue. For example, in the evaluation note, the physical therapist indicated that a patient was uncertain if he or she would go home upon discharge of if he or she would go to stay with a family member. In this case, you would want to follow up with the patient to determine if a decision had been made. As a formal review, the systems review only occurs during the initial evaluation; however, you should always be on alert and document any general issues regarding other systems that are not being addressed by the physical therapist’s plan of care. For example,

Writing the Subjective Section 81

you might be working with a patient on lower-extremity strengthening after an orthopedic surgery when you notice a change in cognitive status that has no correlation with anything in the patient’s medical record. In this case, you would document your observations and contact the physi- cal therapist. Finally, during every patient encounter, you will need to ask questions related to the information in the areas of current condition(s), activities, and participation. You should make a mental note of the information in the initial evaluation and any interim notes to determine spe- cific questions that you need to ask. For example, a thera- pist documents that a patient stated that she was unable to tie her shoes due to back pain. You should ask the patient specifically about that functional task.

Before we look at specifics about what to document in the subjective section and how to structure the note, we need to consider the problem section.

PROBLEM (PR) You will need to record the problem prior to recording

the subjective information. The problem section of the SOAP note answers the question, “What is the main prob- lem?” In an interim note, you should document the diag- nosis or main physical therapy problem. This information helps to provide a context for the rest of the documentation. You can find this information in the initial evaluation. In this section, you may also include the results of any new tests or procedures from the medical record, such as radio- graphs or laboratory results (Example 8-1).

SUBJECTIVE (S) After recording the problem, you can begin to record the

subjective information. As listed previously, information related to the patient’s status and progress, the patient’s reaction to interventions provided, and new problems or complaints should be included. Additionally, any informa-

tion not previously documented that provides insight into the patient’s progress should be included.

The following sections are examples of subjective infor- mation that you might need to include in the interim note.

Patient Status Any comment that helps to paint a picture of the

patient’s functional status should be included. A focus should be on patient or caregiver statements that commu- nicate the patient’s ability to perform functional activities and to participate in home and community roles. Examples of information that provide insight into the patient’s status include the following:

• Pain rating and description. For example, a 48-year- old man who is recovering from a back injury was asked to rate his pain using a numerical scale of 0 to 10 (0 = no pain and 10 = worst possible pain). The patient currently rates his pain as 3/10 and describes the pain as a “pulling” pain.

• Patient’s perception of symptoms. For example, a 76-year-old man in a skilled nursing facility who is recovering from an exacerbation of chronic obstruc- tive pulmonary disease reports, “I am feeling stronger.”

• Patient’s functional abilities. For example, a 35-year- old woman recovering from complications resulting from a radical mastectomy reports, “I was able to put the dishes into the cabinet last night for the first time since my surgery.”

• Statements that demonstrate the patient’s cognitive or emotional status. For example, an 84-year-old woman, recovering from an open reduction and inter- nal fixation of a fractured femur, has been a widow for several years and was living alone prior to the accident. While in therapy, the patient states that her husband is waiting in her room to take her dancing.

• Comments related to the accomplishment of goals/ outcomes. For example, you are working with a 32-year-old woman who is recovering from a humeral fracture. One of her personal goals is to be able to care for her 10-month-old infant. Today, in the clinic, she proudly reports, “I was able to change the baby’s diaper last night all by myself.”

Patient Response to Interventions Provided

• Behavior of the patient’s pain since the previous intervention. For example, a 52-year-old woman is receiving therapy due to a diagnosis of adhesive cap- sulitis. The patient states that her pain level increased after her last therapy session when a new stretching activity was initiated, but she reports that the increase in pain only lasted approximately 1 hour and then the pain returned to its normal level.

Example 8-1 Problem Component of Interim Note

Anytown Community Hospital: Skilled Nursing Facility

Physical Therapy Daily Note Patient: D.T. Date: 04/04/16 Pr: Left patellectomy; (L) LE ROM and strength

deficits; gait deficits impacting home and work life.

Chapter 882

• Comments that demonstrate whether the interven- tion provided is effective. For example, a 64-year-old man with chronic cervical pain has received a trial of transcutaneous electrical nerve stimulation. The patient reports no relief of pain symptoms with the transcutaneous electrical nerve stimulation trial.

New Problem(s) or New Complaint(s) • New pain complaints. For example, a 77-year-old male

patient is recovering from an elective total hip arthro- plasty. The patient had medical complications and was on bed rest longer than anticipated, and his recovery has been delayed. As you begin working with him, he states that his heels have been very sore from lying on the bed so much.

Pertinent Information Not Previously Documented

• Medical history. For example, you are working in an outpatient setting. You have been assisting with the care of a 48-year-old man who injured his back while moving. Today, as you are working with him, he informs you that he had a hernia repair 2 years ago. You know that this information was not included in the initial evaluation or any of the subsequent interim notes.

• Environment. Lifestyle, home situation, work, school. For example, you have been assisting with the care of a 72-year-old man in a skilled nursing facility. He had a femur fracture and will be non-weighbearing for 6 to 8 weeks per the physician’s report. The patient’s goal is to return home, where he lives alone. You know from the evaluation note that the patient has 4 steps without any railing to enter his home. As you are working with the patient, he reveals that his “steps” are nothing more than cinder blocks stacked on top of each other.

Informed Consent A final area that you may need to include in the sub-

jective portion of the note is informed consent. Informed consent is a method of informing the patient of the treat- ment or care you will be providing. Initially, the physi- cal therapist obtains informed consent when discussing the plan of care with the patient; however, you might be required to obtain informed consent when implementing a new modality. In this case, you are required to explain the procedure, determine the presence of contraindications, and describe risks and benefits where appropriate. You will want to record the patient’s consent to the new intervention in the subjective area of the interim note.

STRUCTURE/ORGANIZATION OF SUBJECTIVE DATA

The subjective data are often highly organized in the ini- tial evaluation note. The physical therapist will often cate- gorize information under subheadings to provide structure to the note and to allow for a logical flow of the informa- tion. Subheadings for the information can vary and may be delineated by facility policy. When writing an interim note, subheadings are not generally necessary. You should organize the subjective information by grouping similar information. You should keep all information related to the patient’s pain (rating, description, and behavior) together and keep all information related to the home environment (distance needed to walk, steps to negotiate, type of floor- ing) together. There may be a few occasions when you will need to document many pieces of subjective information. In this case, you can use subheadings to organize the infor- mation. When possible, use the same subheadings used by the physical therapist in the initial evaluation. Subheadings that might be used in the subjective section include the following:

• Current condition • Patient complaint(s) • Living environment • Functional status/activity level • Medical/surgical history • Family health history • Social history • Employment status

TIPS FOR WRITING SUBJECTIVE INFORMATION

When writing the subjective information, it is important to do the following:

• Indicate exactly who is providing the information (eg, the patient, the patient’s spouse, the patient’s son or daughter, the caregiver).

• Use verbs such as states, reports, complains of, denies, and describes.

• Use quotes to demonstrate the patient’s cognitive or emotional status or attitude toward therapy.

• While the first word of the subjective is usually “patient,” it is not necessary to repeat “patient” at the beginning of every sentence. Once it is written the first time, it is implied in subsequent sentences (Example 8-2).1

Writing the Subjective Section 83

REFERENCE 1. Kettenbach G. Writing SOAP Notes. 2nd ed. Philadelphia,

PA: F.A. Davis; 1995. Example 8-2

Subjective Component of Interim Note S: Patient complains of continued weakness

in left knee. Reports being ambulatory with no assistive device when at home, uses one crutch when on uneven surfaces, outside of the home. States that he has made moder- ate improvements with therapy.

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REVIEW QUESTIONS 1. What are the types of information that should be documented in the subjective portion of an interim SOAP

note?

2. Identify appropriate sources for obtaining subjective information. Compare and contrast the validity of each source.

3. Indicate the preferred source (patient, patient’s family member/caregiver, patient’s medical chart) to obtain the following information, and describe why that is the preferred source.

Number of steps leading into the home Description of pain Patient’s ability to get in/out of bed Patient’s prior health status Last time pain medication was taken Sleep patterns Patient’s adjustment to a permanent disability Distance from the bed to the bathroom School-related expectations for a pediatric client

Writing the Subjective Section 85

APPLICATION EXERCISES I. Write the following statements in a more clear and concise manner, as they would appear in the medical record.

Indicate the subheading that the information would fall under.

1. The patient said that his global functional rating is 85% on a 100-point scale.

2. The patient said that he is planning to return home after he is released from the hospital.

3. The patient’s wife said that the patient has not been able to get up out of bed by himself for the past 2 weeks.

4. The patient said that he has not been able to complete his work tasks because he gets tired and must sit down about every 5 minutes.

5. The patient’s husband tells the physical therapist assistant that to get from the car to the house the patient must walk about 25 feet over grass and then will need to go up 4 steps and that the steps do not have a railing.

II. Organize the following information so that it is clear, concise, and suitable for entry into the medical record.

1. You are working with Mr. Jones, who injured his hand in a work accident. He complains of continued swelling in his fingers. He says that he has pain at a level of 7 out of 10 on a 10-point scale. He says that he has not been able to make a fist and that has had difficulty with getting dressed and eating due to the swelling and pain in his hand.

2. Upon seeing a child for a school-based intervention, the teacher tells you that she noticed a red spot on the arch of the child ’s right foot after removing his “leg brace” (a rigid ankle-foot orthosis). She also tells you that the child is refusing to walk in the classroom and doesn’t put weight on his right foot when transferring in or out of his wheelchair.

3. You are seeing a 2-year-old girl in the state’s Early Intervention Program. She has a congenital right transtibial amputation. She is in foster care. During the session, the foster mom tells you that the child will be getting fit for a new prosthesis and that her doctor recommended that she go to a rehabilitation hospital to learn how to use it.

4. A 19-year-old patient is in a coma after a motor vehicle accident. The patient’s mother states that the patient is a very active individual and is involved in basketball and baseball. The mother says that the patient was attending college at the local university and has been living in the dorm rooms. The mother states that the patient has been responding to her by squeezing her hand, but the patient has not said anything to her.

Rebecca McKnight, PT, MS

Erickson ML, McKnight R. Documentation Basics for the Physical Therapist Assistant, Third Edition (pp. 87-100)

Writing the Objective Section

Chapter 9

After reading this chapter, the reader will be able to do the following: 1. Identify types of data that should be recorded in the

objective portion of a SOAP (subjective, objective, assessment, and plan) note.

2. Discuss how objective data are used to inform the deci- sion related to the provision of patient care.

3. Describe documentation strategies that demonstrate that skilled care is being provided.

4. Arrange data collected during the objective portion of an interim note into a logically sequenced, objective note.

5. Describe the importance of linking objective informa- tion in the interim note with information in the evalu- ation note.

The objective section of a SOAP note answers the questions, “What is going on with the physical therapy intervention?” and “How is the patient responding to the intervention?” For a physical therapist (or a physical thera- pist assistant to utilize documentation to make appropriate decisions regarding patient care, it is essential that details

regarding the interventions provided and the patient’s responses to those interventions are documented. For example, if you are providing gait training with a patient who requires verbal and tactile cues, specifying details about the cues (eg, amount, location, type, frequency) can help the therapist to get a clear picture of how the patient is performing and to make appropriate decisions regarding needed modifications in the plan of care. Furthermore, these kinds of details are necessary to show that the interventions provided require the problem-solving skills of a physical therapist assistant meeting therefore meet- ing reimbursement requirements. The American Physical Therapy Association (APTA) Defensible Documentation for Patient/Client Management states the following1:

Demonstration of skilled care requires documen- tation of the type and level of skilled assistance given to the patient/client, clinical decision mak- ing (PT) or problem solving (PTA), and continued analysis of patient progress. This can be expressed by recording both the type and amount of manual, visual, and/or verbal cues used by the therapist to assist the patient/client in completing the exercise/ activity completely and correctly.

CHAPTER OBJECTIVES

KEY TERMS Evaluation note | Interim note | Objective data | Procedural interventions | SOAP note

KEY ABBREVIATIONS APTA | FIM | ROM | SOAP

Chapter 9

Objective data used to describe the patient’s response to interventions is obtained through various methods and techniques, such as range of motion (ROM) mea- surements, gross muscle testing, sensation testing, girth measurements, and functional tests. When possible, these methods are based on clearly defined procedures and are therefore reproducible. Using reproducible methods helps to improve the validity and reliability of the data obtained. Because objective data are gathered through reproducible procedures, the information is verifiable and therefore use- ful for validating the need for physical therapy services. Measurements documented in an interim note are com- pared with those documented in the initial evaluation and future documentation to demonstrate the patient’s progress throughout the episode of care. Objective data help to form a detailed picture of the patient and the problem(s) and are used to guide the physical therapy decision-making process.

It is important to remember that the primary goal of physical therapy should be to impact the individual at the activity or participation level. Documentation of objective data should therefore indicate the patient’s functional sta- tus. When documenting measurements of body structure and function impairments, it is important to correlate those impairments with limitations in the patient’s functional activities. For example, instead of just documenting a limi- tation in shoulder ROM (right shoulder flexion active range of motion [AROM] 0-110°), you should document how the restriction impacts the individual’s daily function (patient right shoulder AROM 0°-110° limiting ability to perform daily tasks including reaching items in kitchen cabinets). Reimbursement is typically tied to improvement in func- tion, thus, the documentation of limitations in a patient’s functional abilities helps to justify the need for physical therapy services. Finally, a focus on function helps to moti- vate patients to participate in interventions because func- tional activities are more meaningful to them. For example, a patient is not as interested in how many degrees of motion she has available in her shoulder joint, but she is interested in having adequate range so that she can comb her hair.

INTERIM NOTE Objective data found in the interim note should show

clear connections with the physical therapist evaluation. Interventions provided by the physical therapist assistant should be included in the plan of care (plan section of a SOAP note), and test and measures documented should demonstrate connections between measurements found in the evaluation and should correlate with goals that are being addressed.

Objective information in an interim note falls into one of the following 3 categories: (1) information that demon- strates the patient’s readiness to participate with physical therapy, (2) physical therapy intervention(s) provided, or (3)

information that demonstrates the patient’s response to the physical therapy intervention provided. Let’s take a closer look at these 3 areas and the type of information that you will need to record in an interim note.

Data Indicating That It Is Safe for Patient to Participate in Selected Interventions

Prior to initiating any intervention, you will verify that the patient’s physiologic status is adequate for the patient to participate in the activities as planned. Various objective data may need to be evaluated depending upon the patient’s condition and the specific intervention(s) provided. For example, you are working with a patient who has had a stroke and is receiving therapy for functional training, including transfers and gait training. Prior to beginning these activities, you would need to ensure that the patient is physiologically safe to participate through assessing the patient’s cardiovascular status and general cognitive status. In another example, when working with a patient who is receiving physical therapy for gait training following a total hip replacement, you will want to observe the patient’s surgical leg to monitor for symptoms of a deep vein throm- bosis. Potential areas and types of data that may need to be performed prior to the initiation of interventions to ensure that the patient is safe to participate include the following 2,3:

• Aerobic capacity/endurance: Heart rate, blood pres- sure, respiratory rate, and monitor response to position changes (orthostatic hypotension).

• Balance: General observation of sitting and/or stand- ing balance.

• Circulation: Peripheral pulses, general observations of edema, skin color, and nail color.

• Mental functions: Orientation (to situation, time, place, and person), ability to process commands, and level of arousal.

• Pain: Location, intensity, and changes with posture/ movement.

• Sensory integrity: General observations of the patient’s ability to process sensory information.

• Ventilation and respiration: Oxygen saturation, respi- ratory rate and rhythm, and skin color.

Interventions Provided As noted previously, when documenting interventions

provided, it is important to include details and to focus on the patient’s function. General areas that should be included when documenting interventions area communication and coordination, patient-related instruction, and procedural interventions. Some examples are provided here. Later in the chapter, we look at specific components that need to be included for different interventions.

Writing the Objective Section 89

• Communication and coordination: Discussion with the nursing staff about the patient’s pain medication schedule.

• Patient-related instruction: Education related to hip precautions with a patient who is recovering from a total hip arthroplasty.

• Procedural interventions: Transfer and gait training, therapeutic exercise program, and physical agents.

Patient’s Response to Physical Therapy Intervention Provided

Documentation of the patient’s response to the interven- tions is essential to demonstrating the patient’s progress and to demonstrate that the interventions require the problem-solving skills of a physical therapist assistant. In addition, a full description of interventions provided helps to support billing or timed procedures. Patient’s responses can be demonstrated through the following examples:

• Results of data collected: Through techniques such as goniometry or manual muscle testing.

• Description of patient’s function: Description of the patient’s ability to move around in bed.

• Observations about patient: Any general observations that cannot be categorized as data from a specific tech- nique or a description of function, including informa- tion such as description of an open wound, description of patient’s movement strategies, or documentation of tenderness to palpation.

STRUCTURE/ORGANIZATION OF OBJECTIVE SECTION (O)

There is no universal standard structure for the docu- mentation of objective data. Many facilities establish stan- dards that should be followed. In the case where a standard does not exist, the information should be presented in a logical sequence to assist the clinical decision making of all involved in patient care and to allow reviewers of the docu- mentation to determine details about the care provided. To allow for easy identification of data, it is necessary to organize the information with the use of subheadings. You should refer to the initial evaluation and use the same subheadings found there, when possible. This will allow individuals to find information quickly and easily, to cor- relate the information with the initial evaluation and to determine the patient’s progress toward the established goals. In addition, when documenting interventions, it is important to clearly distinguish the intervention from the tests and measures data. This can be accomplished by sepa- rating tests and measures data from the interventions data and by clearly labeling each. When you have information that does not easily fall within the subheadings noted in the initial evaluation note, you may choose alternative sub-

headings. Appropriate subheadings for tests and measures data can be found in Sidebar 2-2. A thorough description of each of area, including definitions, examples of clini- cal indications, examples of what tests and measures may characterize or quantify, examples of data-gathering tools, and examples of data used in documentation can be found in the APTA Guide to Physical Therapist Practice.2

In addition to the tests and measures data, you should include an “interventions provided” section. Information in this section should include any collaboration and com- munication with other health care providers or the physi- cal therapist, patient/client instruction, and all procedural interventions provided.

Often, information in the objective section is best com- municated in list, column, or table format. These formats are used to make the information easier to follow. Columns or tables are also used to document comparative data, such as previous status compared with current status or prein- tervention measurements compared with postintervention measurements. Information that is frequently documented in this format includes goniometric and manual muscle test results.

Example: AROM PROM Strength

(R) hip abduction 20 30 2-/5

Adduction 0 10 2-/5

Flexion 80 95 3-/5

Extension 0 5 2+/5

(R) Knee 10-100 5-120 3-/5

(R) Ankle DF 5 20 3-/5

PF 45 45 4/5

Inv 20 30 3+/5

Ev 5 15 3+/5

GENERAL TIPS • When documenting results of tests and measures, it is

important that all pertinent information be included to allow for the reproduction of the test. Standard testing procedures will be assumed, therefore, if any alterations to the procedure are used, they should be clearly detailed.

• Document results of tests and measures in the same manner as they were performed and documented in the physical therapist’s initial evaluation note. Use the same scale used in the initial evaluation.

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• All data should be recorded in relation to what the patient did, not what the physical therapist assistant did. For example, when documenting gait, the note would read as follows:

º Gait: Patient ambulated 100’ with a straight cane on level surfaces requiring moderate assistance of 1.

Not º Gait: The physical therapist assistant walked the

patient 100’ providing moderate assistance. • As with subjective data, complete sentences are not

a requirement, as in the above example; however, all pertinent information needs to be included.

• Not all information addressed in the initial evaluation needs to be addressed in each interim note.

º Only address data obtained while reassessing the patient during the treatment session.

º It is not necessary to address areas that were found to be within normal parameters in the ini- tial examination/evaluation if those areas are still normal.

• A copy of any written instructions provided to the patient should be included in the medical record and referred to in the objective section of the note.

• Use verbs such as demonstrated, performed, and is.

TIPS FOR DOCUMENTING INTERVENTIONS PROVIDED

When documenting interventions provided, include all information that is necessary to reproduce the activity (Example 9-1), as follows:

• Intervention provided: Specify what intervention was provided (eg, modality, exercise, gait training).

• Intervention amount: Indicate the dosage or amount of the intervention provided (eg, number of repeti- tions, distance covered).

• Equipment used: Indicate any equipment used dur- ing the intervention (eg, transcutaneous electrictrical nerve stimulation, 5-lb weight, standard walker).

• Parameters: Provide the parameters/settings used with the equipment (eg, ramp on/off time with electri- cal modalities, pounds of traction).

• Treatment area: Indicate the specific area of the patient’s body that was treated (eg, left biceps, insertion of the right deltoid).

• Patient positioning: Specify patient positioning used during the session unless it is a standard position for the specific intervention (eg, indicate patient in side lying or indicate exercises were provided in a gravity- reduced position).

• Details: Include the duration, frequency, and number and length of rest breaks.

• Alterations: Include anything that would not be con- sidered standard practice.

• Time: Include the time of each intervention and total treatment time.

In addition, you will want to document the following information related to each of these areas.

DOCUMENTING COMMUNICATION/ COORDINATION

• Any communication with the supervising physical therapist

• Communication with other health care practitioner (eg, physician, registered nurse, occupational therapist, prosthetist)

• Conversations with administrators or case managers • Phone conversations with any of the above

Example 9-1 O: AROM (L) knee Pretreatment Post-treatment Flex 0° to 135° 0° to 140° Strength: (L) LE quads 3+/5, hamstrings 4-/5, mild discomfort noticed with knee extension. Gait: Able to ambulate 250’ without assistive device or immobilizer independently but does display

decreased cadence and guarding. Demonstrates abnormal heel to toe gait pattern and has a tendency to keep LE extended when walking.

Treatment: (L) LE ham curls prone 2 x 10, 5# long are quads 2 x 10 1#, straight leg raise 2 x 10 no weight. Initiated closed chain knee bilateral bends for proprioceptive retraining 3 x 30.

Writing the Objective Section 91

DOCUMENTING PATIENT-RELATED INSTRUCTION

• Therapeutic activity instruction (eg, home exercise program)

• Precautions/restricted activity (eg, total hip precau- tions, lifting restrictions)

• Education related to disease process (eg, what is a stroke?)

• Education related to physical therapy procedures (eg, what is ultrasound, and why is it used?)

• Family/caregiver instruction

PROCEDURAL INTERVENTIONS Procedural interventions are the techniques and proce-

dures used in physical therapy to affect positive change in the patient’s condition. The following is a list of categories of interventions. Each is followed by a list of types for each category and some have additional documentation tips.

• Airway clearance techniques º Types

■ Breathing strategies (eg, paced breathing, pursed lip breathing)

■ Coughing techniques ■ Secretion mobilization (eg, chest percussion,

postural drainage) • Application of devices and equipment

º Types ■ Aids for locomotion (eg, crutches, canes,

walkers, rollators, manual wheelchairs, power wheelchairs, power-operated vehicles)

■ Orthoses (eg, ankle-foot orthoses, knee-ankle- foot orthoses, body jackets, wrist cock-up splints, shoe inserts)

■ Prostheses ■ Seating and positioning technologies ■ Other assistive technologies to improve safety,

function, and independence (eg, transfer boards, mechanical lifts/hoists)

• Biophysical agents º Types

■ Biofeedback ■ Compression therapies (eg, compression gar-

ments, vasopneumatic compression devices) ■ Cryotherapy (eg, cold packs, ice massage) ■ Electrical stimulation (eg, muscle, nerve) ■ Hydrotherapy (eg, contrast bath, pools, whirl-

pool tanks) ■ Light agents (eg, laser)

■ Mechanical devices (eg, continuous passive motion device, tilt table, traction devices)

■ Sound agents (eg, ultrasound) ■ Thermotherapy (eg, hot packs, paraffin baths)

º Information to include in documentation ■ Specific physical or mechanical agent used ■ Patient position ■ Specific area treated ■ Exact settings used ■ Duration of treatment

• Functional training in self-care and domestic, work, community, social, and civic life

º Types ■ Activities of daily living training (eg, bed

mobility, transfer training) ■ Barrier accommodations or modifications ■ Developmental activities ■ Functional training programs (eg, simulated

environments and tasks, work conditioning) ■ Instrumental activities of daily living training

(eg, school and play activities training) º Information to include in documentation

■ Specific activity (eg, bed to wheelchair trans- fers)

■ Assistive/adaptive devices used • Integumentary repair and protection techniques

(wound management) º Types

■ Biophysical agents (eg, electrical stimulation) ■ Debridement (eg, autolytic, mechanical,

pulsed lavage with suction) ■ Dressings (including application and removal) ■ Isolation and sterile technique ■ Topical agents

º Include in documentation ■ Isolation or sterile techniques used (eg, gown,

gloves) ■ Type and amount of dressing used ■ Precautions for dressing removal

• Manual therapy techniques º Types

■ Manual lymphatic drainage ■ Manual traction ■ Massage ■ Passive ROM

º Include in documentation ■ Side(s) (right or left), joint(s), and motion(s) ■ Number of repetitions or time ■ Location ■ Type of massage

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• Motor function training º Types

■ Balance training (eg, developmental activities, motor control training, neuromuscular re- education)

■ Gait and locomotion training (eg, developmen- tal activities, use of assistive devices, wheel- chair propulsion)

■ Posture training (postural awareness, postural stabilization activities)

• Therapeutic exercise º Types

■ Aerobic capacity/endurance conditioning or reconditioning (eg, movement efficiency, energy conservation training, walking, and wheelchair propulsion programs)

■ Flexibility exercises (eg, ROM, stretching) ■ Neuromotor development training (eg, devel-

opmental activities training) ■ Relaxation (eg, breathing strategies, relaxation

techniques) ■ Strength, power, and endurance training (eg,

active-assistive, active and resistive exercises and task-specific performance training)

º Include in documentation ■ Specific activities/exercises performed ■ Equipment used ■ Patient position (if not clear by use of equip-

ment) ■ Repetitions ■ Time spent

RESPONSE TO INTERVENTIONS Documentation of the patient’s response to interventions

will depend somewhat on the type of response and the intervention. Some responses will be recorded in the tests and measures section of the note. Examples include record- ing pre- and postheart rate and blood pressure readings and documentation of the amount and type of assistance required during gait training. At other times, the patient’s response to interventions is embedded in the description of the intervention or immediately follows the description. For example, when documenting the patient’s response to shoulder exercises, after a detailed description of the exer- cise (movement, resistance, etc), you would document the patient difficulty performing the exercise without undesir- able substitutions.

Tips for Documenting Results of Data Collected

When documenting results of data collection, include all information needed for the test to be reproduced and for the results to be clearly understood. Be sure to include the following:

• Procedure utilized (eg, goniometry, manual muscle testing, observation)

• Exactly what was measured (eg, right elbow flexion PROM)

• The patient’s position

Types of Data Collected

Vital Signs (indicate before and/or after exercise/activity as appropriate)

• Heart rate º Location º Quality º Rate

• Respiratory rate º Rate º Rhythm º Depth º Regularity of pattern

• Blood pressure º Location, side º Systolic over diastolic (eg BP: (R) brachial 120/80)

Anthropometric Characteristics • Height • Weight • Length • Girth

Muscle Strength • The measurement range (eg, when documenting

strength for right elbow flexors document 3/5 instead of 3)

• What is measured º Muscle group (eg, hip flexors) º Specific muscles (eg, gluteus maximus) º Arrange logically (group per anatomical location

[eg, group shoulder musculature together: shoulder flexors 4/5, extensors 4-/5, abduction 4-/5, adduc- tion 4+/5])

º Use tables or columns to show (B) measurements or before/after measurements

Writing the Objective Section 93

• Any deviation from standard position/protocol (eg, tested hip extension in sidelying due to patient unable to get in prone because of obesity)

Pain • Results from written pain questionnaires, scales, and

diagrams (eg, the McGill Pain Questionnaire, Pain Disability Index, visual analogue scales, pain drawings, pain maps)

• Note: Verbal descriptions of pain given by the patient are often included in the subjective portion of the note. Sometimes, data from pain questionnaires are also recorded in the subjective portion of the interim note.

• Describe patient’s nonverbal pain responses to activi- ties, positioning, and postures

Range of Motion • Document the range from the beginning of the range

available to the end of the range available (eg, elbow flexion 5° to 110° instead of just elbow flexion 110°)

• Specific joint • Arrange logically • Group per anatomical location • Use tables or columns to show (B) measurements or

before/after measurements • Any deviation from standard position/protocol (eg,

shoulder external rotation; unable to achieve standard test position due to pain restrictions; pt. placed in 45° of abduction for measurement)

Results of Any Standard Tests or Questionnaires

• Record measurements per the standard of the test being used (eg, Berg Balance Scale)

Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic Devices

• Specify device being used (eg, left custom ankle-foot orthosis)

• Discuss patient’s (patient’s family’s/caregiver’s) ability to care for device

• Discuss patient’s ability to don/doff device as appropriate

• Discuss skin condition related to use of the device • Discuss safety risks associated with use of the device

Gait, Locomotion, and Balance • Indicate activity (eg, gait, wheelchair mobility) • Indicate any assistive, adaptive, orthotic, protective,

supportive, or prosthetic devices used (eg, wheeled walker)

• Indicate type of surface the patient is traversing (eg, level surface, stairs)

• Indicate distance traveled or amount of time activity is tolerated (eg, 100 feet, 10 minutes)

• List amount and type of physical assistance provided (eg, patient required minimal assistance to place left lower extremity)

• Number of people needed to aid (eg, patient required minimal assistance of 2 people). If no number is pro- viding, then assume it is 1 person

• List amount and type of cues given (eg, patient required constant verbal cues for cane placement)

• Describe gait pattern used, if appropriate (eg, 4-point gait pattern)

• Describe gait deviations, if appropriate (eg, patient demonstrated left foot drop during swing phase of gait)

• When documenting gait, include weightbearing status

Self-Care, Home Management, and Community or Work Reintegration

• Record measurements of physical environments • Record any safety concerns or barriers in home, com-

munity, and work environments

Results of Any Standard Tests or Questionnaires

• Record measurements per the standard of the test being used (eg, Functional Independence Measure [FIM], 36-Item Short Form Health Survey)

To provide greater objectivity and reliability when docu- menting functional status, some clinics and facilities use standardized tests or questionnaires to measure impair- ments, function, and degree of disability. Each test or ques- tionnaire will have specific directions related to appropriate documentation to allow for consistency of administration and scoring. When using a standardized tool, the clinician and facility will want to verify its validity and reliability. Specific tools are designed for specific patient populations. A tool that has been determined to be valid in one setting may not be appropriate in another. Finally, traditional grading of function (eg, independent, minimal assistance) should be consistent with scoring given on standardized instruments. Table 9-1 demonstrates a comparison of docu- mentation of functional status utilizing traditional termi- nology and scoring utilizing the FIM, a standardized test for measuring a patient’s function. Other functional mea- sures can be found in Table 9-2 and in the Rehabilitation Measures Database at www.rehabmeasures.org. The APTA provides its members with an online resource, PTNow, which provides information about many standardized tests. The website provides a description of the test, information about the validity and reliability of the test, a copy of the test, and reference: http://www.ptnow.org/Default.aspx.

Chapter 9

Table 9-1 Documentation of Functional Status Using Traditional Terminology Versus FIM Scores

Abbreviation Definition Amount/Type of Assistance Needed

FIM Score Descriptor Amount/Type of Assistance Needed

(I) Independent No assistance needed

7 Complete independence

All of the tasks described as making up the activity are typically performed safely, without modification, assistive devices, or aids, and within a reasonable amount of time

No direct correlation with FIM score 6 Modified independence

One or more of the following may be true: • The activity requires an assistive device

• The activity takes more than reasonable time

• There are safety risks

SBA Standby assist

Patient needs someone close by for safety or to provide verbal or visual cues

5 Supervision or setup

Patient requires no more help than standby, cueing or coaxing, without physical contact, or helper sets up needed items or applies orthoses or assistive/ adaptive devices

CGA Contact guard assist

Patient needs someone touching him/ her for safety or to provide physical cues

No direct correlation with FIM scores

Min Minimal Patient performs 75% or more of the effort

4 Minimal contact assistance

Patient requires no more help than touching and expends 75% or more of the effort

Mod Moderate Patient performs 25% to 75% of the effort

3 Moderate assistance

Patient requires more help than touching or expends half or more of the effort (50% to 75%)

Max Maximal Patient performs 25% or less of the activity

2 Maximal assistance

Patient expends less than 50% of the effort but at least 25%

Abbreviations: CGA, contact guard assist; FIM, Functional Independence Measure; (I), independent; Max, maxi- mal; Min, minimal; Mod, moderate; SBA, standby assist.

Writing the Objective Section 95

Table 9-2 Outcome Measures and Their Target Patient Population

Outcome Measure

Acute Care Index of Function (ACIF) Arthritis Impact Measurement Scale (AIMS2) Asthma Quality of Life Questionnaires Cardiac Health Profile Dallas Pain Questionnaire Diabetes Impact Measurement Scale (DIMS) Disability Rating Scale Fatigue Impact Scale Fibromyalgia Impact Questionnaire Foot Function Index Frail Elderly Functional Assessment Functional Independence Measure (FIM) Functional Performance Inventory

Fugl-Meyer Assessment Scale Gross Motor Performance Measure (GMPM) Gross Motor Function Measure (GMFM) Harris Hip Scale Neck Disability Index (NDI) Oswestry Low Back Pain Disability Questionnaire Parkinson’s Disease Quality of Life (PDQL) Patient-Rated Wrist Evaluation (PRWE) Peabody Development Motor Scales Pediatric Evaluation of Disability Index (PEDI) Physical Disability Index 12-Item Short Form Health Survey (SF-12) 36-Item Short Form Health Survey (SF-36) Sickness Impact Profile (SIP)

Stroke Impact Scale Therapeutic Associates Outcomes System Western Ontario and McMaster Universitites Osteoarthritis Index WeeFIM

Patient Population

Acute neurological Arthritis Asthma Cardiovascular disease Chronic spinal pain Type 1 and type 2 diabetes Severe head trauma Chronic disease Fibromyalgia Foot pain Frail elderly Variety Moderate to severe chronic obstructive pulmonary disease Cerebrovascular accident Children with cerebral palsy Pediatric Hip arthritis Neck disorders Low back disorders Parkinson’s disease Wrist disorders Pediatric motor development Pediatric Frail elderly Variety Variety Variety with versions for nursing home residents and stroke Cerebrovascular accident Variety of musculoskeletal disorders Osteoarthritis

Pediatric function

Chapter 9

Arousal, Mentation, and Cognition • Describe changes in patient’s state of arousal, menta-

tion, and cognition (eg, pt. lethargic today; difficult to arouse and attend to therapeutic activities)

Integumentary Integrity • Location of wound/skin condition • Size of wound • Depth of wound • Location and depth of any tunneling/undermining • Description of tissue • Description of surrounding area • Description of drainage • Description of odor • Activities, positioning, and postures that aggravate or

relieve pain, alter sensation, or produce associated skin trauma

Joint Integrity and Mobility • Describe abnormal joint movements/end feels

Muscle Performance • Describe abnormal muscle mass (eg, left lower-extrem-

ity gastrocnemius atrophy compared to right lower extremity)

• Describe change in muscle tone (eg, noted hypertonic- ity of right lower extremity during gait with straight cane)

Neuromotor Development • Describe gross and fine motor milestones • Describe abnormal righting and equilibrium reactions

Posture • Describe alignment of trunk • Describe alignment of extremities in relation to trunk

Ventilation, Respiration, and Circulation Examination

• Describe skin color in relation to circulation and ventilation

• Describe symptoms of ventilation/respiratory or circulatory deficiency

• Describe chest wall expansion and excursion • Describe cough • Describe sputum color and consistency

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