2. PHYSICIAN’S ORDER CERTIFICATIONS PATIENT FORMS: INFORMED CONSENT, PERMISSION TO TREAT, INSURANCE FORMS, OR PAYMENT AGREEMENTS, HIPPA REVIEW OF PATIENT CHART
3. PT EVALUATION: PATIENT HISTORY-SOCIAL AND MEDICAL DIAGNOSIS LIVING SITUATION/ASSISTANCE PATIENT GOALS FUNCTIONAL STATUS-PREVIOUS AND CURRENT (TEST AND MEASURES) PLAN OF CARE SHORT TERM GOALS LONG TERM GOALS PT EVALUATION
4. DAILY PROGRESS NOTES FLOW CHARTS, CHECK OFF SHEETS… WEEKLY NOTES 30 DAY RE-EVALUATIONS DISCHARGE NOTE PT DOCUMENTATION
5. EVALUATION- THE PTA IS RESPONSIBLE FOR CLARIFING ANY QUESTIONS WITH THE PT PRIOR TO TREATING THE PATIENT. DAILY/WEEKLY NOTE- THE PTA IS RESPONSIBLE FOR WRITING THE NOTES AND COMMUNICATING WITH THE PT ON PATIENT PROGRESS AND GOAL STATUS. IF GOALS NEED TO BE REVISED THE PTA WILL PROVIDE INFORMATION AND THE PT WILL DEVELOP NEW GOALS. THE PTA’S RESPONSIBILITY
6. RE-EVALUATION- THE PTA CAN COLLECT OBJECTIVE DATA FOR THE PT IF REQUESTED. THE PT WRITES THE RE-EVALUATION AND MODIFES OR DEVELOPS NEW GOALS. (COMMUNICATE, COMMUNICATE, COMMUNICATE) DISCHARGE-THE PT MAKES THE DECISION ON DISCHARGE, BUT THE PTA CAN WRITE THE SUMMARY. IT MUST BE CO-SIGNED BY THE PT THE PTA’S RESPONSIBILITY
7. MANAGE YOUR TIME TO ALLOW FOR DOCUMENTATION (DAILY) IF PAPER DOCUMENTATION IS USED, YOU NEED TO USE BLACK INK TO WRITE YOUR NOTES CROSS OUT MISTAKES WITH 1(ONE) LINE, INITIAL AND DATE MISTAKE DO NOT LEAVE BLANK SPACES IN THE NOTES PEARLS OF WISDOM FOR DOCUMENTATION
8. DO NOT EVER CHANGE ANYONE ELSES NOTE ACCURACY BREVITY CLARITY ALWAYS SIGN AND DATE YOUR NOTES PEARLS - CONTINUED
9. IF IT IS NOT WRITTEN DOWN IT DID NOT HAPPEN!! MOST IMPORTANTLY
10. WHEN YOU HAVE ANY QUESTION ABOUT THE PATIENT’s PLAN OF CARE OR NEED CLARIFICATION WHEN THERE IS AN UNEXPECTED CHANGE/ OR NON-CHANGE IN PATIENT STATUS PRIOR TO RE-EVALUATION WHEN THERE IS A NEED FOR CHANGE OF THE PLAN OF CARE (POC) WHEN TO COMMUNICATE WITH YOUR PT
11. WHAT MAKES SOMETHING SKILLED? WHAT MAKES SOMETHING MAINTENANCE? SKILLED THERAPY VS. MAINTENANCE
12. Pt. to be seen for PT BID. Pt. dx AKA R LE X 2wk, COPD,& DM. Pt. uses CPAP n.s.. PT to include AAROM R hip. Pt. will be seen by COTA for AROM B UE. PRACTICE 1
13. Mr. Jones was admitted to the hospital for CABG x 3 2 ̊ CAD x10 years. Pt. NPO except for po medications prior to surgery. PT amb pt bid & to monitor BP during amb. DC activity with c/o chest pain. PRACTICE 2
14. Susan Miller is 26 yo ♀. DOB 1/23/1985. DOI reported as a fall 6/1/2011 . C/O difficulty with DF & AFO was ordered as part of DME. Pt. was instructed in AP & and performed with @. Pt. dxCP complicated by the fall. Amb with AFO no AD CGA. PRACTICE 3
15. Tim Fowler was sent to physical therapy from Doctor of Osteopathy Moore. Computer axial tomography scan shows decreased muscle mass above the elbow but ruled out bone cancer. Deep tendon reflexes diminished with suspected central nervous system lesion. PRACTICE 4
16. PLEASE COMPELTE QUESTIONS 1,3,5 ON PAGE 19 OF YOUR TEXT BOOK. COMPLETE IT IN A WORD DOCUMENT AND ATTACH IN THE ASSIGNMENT LINK. FOR TEST BE PREPARED TO SEE ABBREVIATIONS A-L ASSIGNMENT
