Documenting the Evaluation (A) (Assessment)

Chapter 11 Writing the Diagnosis

Differences Between a Therapy Diagnosis and a Medical Diagnosis A therapy diagnosis describes the impact functional deficits or impairments have on a person’s ability to function normally A therapy diagnosis describes the impact functional deficits or impairments have on a person’s ability to function normally A medical diagnosis uses categories to describe medical signs and symptoms and directs medical interventions A medical diagnosis uses categories to describe medical signs and symptoms and directs medical interventions Both therapists and medical doctors will refer to appropriate professionals Both therapists and medical doctors will refer to appropriate professionals Athletic Trainers = Assessments Athletic Trainers = Assessments

An Athletic Trainer will base their assessment on their knowledge and findings from the Subjective and Objective sections of the evaluation. An Athletic Trainer will base their assessment on their knowledge and findings from the Subjective and Objective sections of the evaluation.

Chapter 12 Writing the Prognosis

A prognosis predicts the amount of time needed to reach a desired level of function A prognosis predicts the amount of time needed to reach a desired level of function It takes into account the patient’s rehabilitation potential, severity of injury, and other factors influencing the patient It takes into account the patient’s rehabilitation potential, severity of injury, and other factors influencing the patient It is a professional opinion It is a professional opinion

Documenting the Plan of Care (P)

Chapter 13 Writing Expected Outcomes (Long-Term Goals)

Reasons for Writing Expected Outcomes To help plan interventions to meet the specific needs and problems of the patient To help plan interventions to meet the specific needs and problems of the patient To set priorities between interventions and measure the effectiveness of the interventions To set priorities between interventions and measure the effectiveness of the interventions To assist with monitoring cost effectiveness To assist with monitoring cost effectiveness To communicate the therapy goals for the patient to other health-care professionals To communicate the therapy goals for the patient to other health-care professionals

The Structure of Outcomes and Goals Audience Audience Behavior Behavior Condition Condition Degree Degree Functional Terms Functional Terms Time Span Time Span

Revision The patient’s condition may change and does not allow progression to functionally level originally set The patient’s condition may change and does not allow progression to functionally level originally set The patient’s condition may change and allows progression beyond the functional level originally set The patient’s condition may change and allows progression beyond the functional level originally set The time span is no longer appropriate The time span is no longer appropriate Setting Priorities

Chapter 14 Writing Anticipated Goals (Short-Term Goals)

Reasons for Writing Goals To direct interventions to meet the specific needs and problems of the patient To direct interventions to meet the specific needs and problems of the patient To set priorities between interventions and measure the effectiveness of the interventions To set priorities between interventions and measure the effectiveness of the interventions To assist with monitoring cost effectiveness To assist with monitoring cost effectiveness To communicate the therapy goals for the patient to other health-care professionals To communicate the therapy goals for the patient to other health-care professionals

The Structure of Anticipated Goals Audience Audience Behavior Behavior Condition Condition Degree Degree Functional Terms Functional Terms Time Span Time Span Clarity Clarity

Revision The period mentioned in the goal has passed The period mentioned in the goal has passed The patient has achieved the goals set The patient has achieved the goals set Setting Priorities

Chapter 15 Documenting Planned Interventions

Information Included Under the Plan Frequency of treatment Frequency of treatment The Interventions the patient will receive The Interventions the patient will receive In a discharge note – where the patient is going and the number of times the patient was seen In a discharge note – where the patient is going and the number of times the patient was seen Location of treatment Location of treatment Treatment progression Treatment progression Plans for future assessment Plans for future assessment Plans for discharge Plans for discharge Referral to other services Referral to other services

Writing the Intervention Plan Modalities Modalities Which, where, how long, intensity, position Which, where, how long, intensity, position Ambulation Ambulation Distance, time, weight-bearing, assistance Distance, time, weight-bearing, assistance Exercise Exercise Type, reps, sets, equipment, position, modifications, amount of resistance, Type, reps, sets, equipment, position, modifications, amount of resistance, Home programs Home programs

Chapter 16 Applications and Variations in Note Writing

Applying the P/C Management & SOAP Notes to Other Formats Not all facilities use the same formats Not all facilities use the same formats Narratives Narratives Online Online Fill-in-the-blank Fill-in-the-blank Letters Letters IEPs IEPs Many variations but purpose and information is basically the same Many variations but purpose and information is basically the same

Chapter 17 Alternatives: Documentation Forms, Medicare Forms, and Computerized Documentation

Medicare Forms Medicare uses it’s own forms to decide whether or not the patient qualifies for coverage Medicare uses it’s own forms to decide whether or not the patient qualifies for coverage Contains information gathered in P/C Management form or SOAP note Contains information gathered in P/C Management form or SOAP note

Documentation Forms Decreases amount of writing Decreases amount of writing Increases efficiency and consistency Increases efficiency and consistency Specific to facility Specific to facility Flow sheets, initial examination/discharge note forms, one-visit only forms, supplement forms Flow sheets, initial examination/discharge note forms, one-visit only forms, supplement forms Development of forms Development of forms

Computerized Documentation Dependant on technology Dependant on technology Advantages Advantages Disadvantages Disadvantages