SPC PTHA 1301 Documentation 1 powerpoint

1. The Profession of PT Documentation Basics

2. To restore or bring our patient to the highest level of function. What is the job of the PTA?

3. The ability to do the things we need to do in our daily lives. The ability to be safe in our daily activities. The ability to complete tasks without over- using or injuring other parts of our bodies. Other? Define function:

4. To justify why we see the patient. To see the progress or lack of progress. To allow others to see what the patient can do. Other? Why do we need to document a patients functional level?

5. A report of patient status and progression. Communication with other healthcare providers. Communication with third party payers. A legal document. Justification for what we do. Professional duty. What is documentation?

6. Impairment-is a problem with body function or structure such as a deviation from normal or loss. (Example: fracture of the femur) Activity Limitation- Difficulty in completing a task. (Example: walking and climbing stairs will be difficult if you have a fractured femur) Disablement Model -ICF

7. Participation Restriction- Problems an individual might face during a life situation.(Example: if you have a fractured femur and walking is difficult you will have a hard time getting to classes here on campus) Disability- is the result of impairment, Activity limitation, and participation restriction. IFC continued

8. Pathology- often referred to as the disease/injury being medically managed.(Example: Diabetes is managed by the physician) Impairment-deviations in normal anatomy or physiology. (Example: loss of sensation/feeling in lower extremities from diabetes) Nagi Framework

9. Functional limitations- limitations in ability to carry out meaningful actions, tasks, or activity. ADL’s- IADL’s- Nagi: continued

10. A Little Practice

11. A Little Practice

12. What are the different items included in PT documentation? Initial evaluation- completed by the PT Progress notes- can be completed by the PT or PTA Flow sheets- can be completed by the PT, PTA, and in some clinics the PT tech Documentation

13. Interdisciplinary team documentation of various services provided Re-evaluations- completed by the PT Discharge summary- Can be written by the PTA (in Texas) but must always be reviewed and co-signed by the PT Documentation

14. Physician prescription- Direct Access? Certifications- Payer sources Copies of Any educational materials provided to patient and family members Documentation

15. Questions?

16. Please refer to your assignment calendars and assignment link for: documentation assignment 1-please complete it as a word document and submit it in the assignment link. Have a Great Weekend! Assignment