This document discusses rehabilitation clinical documentation. It emphasizes the importance of using valid and reliable outcome measures to assess patients and determine functional goals and progress. Goals should be based on impairments identified through objective tests and linked to functional limitations. Proper documentation requires justifying medical necessity through measurable changes in function from the patient's perspective.
This study aims to determine if a nurse-delivered discharge planning bundle that includes a follow-up phone call within 1 week of discharge will decrease rapid readmissions of patients with heart failure. The researchers will implement a discharge care bundle including patient education and a follow-up phone call on a hospital unit. They will compare rates of readmission before and after the intervention to see if the bundle reduces readmissions. The goal is to improve patient outcomes and lower healthcare costs for heart failure patients.
Colin Jones presented a case study on his client Eileen, a 68-year-old woman diagnosed with Guillain-Barré syndrome. Eileen was dependent on others for activities of daily living and mobility following her illness. The occupational therapy process included assessments, goal setting to improve independence, and recommending Eileen for rehabilitation. Interventions targeted improving upper limb function and mobility to allow Eileen to return safely to her two-story home.
This research proposal aims to study how strengthening patient-agency, or a patient's ability to manage their own healthcare, can improve outcomes for veterans. The proposal outlines three areas of focus: 1) Developing a standardized method to measure patient-agency in VA settings, 2) Explaining how stressors impact changes in patient-agency over time, and 3) Evaluating how VA programs affect veterans' physical, psychological and economic restoration by changing patient-agency. The goal is to help VA better support veterans' transitions after service by empowering them to direct their own healthcare and treatment.
Hospital-acquired pressure injuries are a significant issue, costing $11 billion annually in the US. A fishbone diagram was used to identify multiple factors that influence pressure injury development, including patient characteristics, materials, staff, processes, environment, and methods. Evidence shows that involving patients in their own care through education on positioning, mobility, and prevention can help reduce injuries. Evaluating prevention strategies and pressure injury rates through staff meetings and assessing staging can help hospitals improve processes and decrease injuries over time.
This document discusses hourly rounding, which involves nurses checking on patients on an hourly basis. It presents national averages for HCAHPS scores and outlines several improved outcomes associated with hourly rounding such as patient satisfaction, safety, and reduced call light usage. The 6P protocol is described which involves greeting the patient and addressing their pain, personal needs, positioning, bathroom needs, and environment. Benefits of hourly rounding include increased HCAHPS scores, hospital reimbursement, and nurse satisfaction and efficiency.
This lecture was given by Dr Rhian Lewis, Consultant in Pain Management from Bangor, North Wales, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. Her lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
www.wspg.org.uk
bioethical considerations for preventative enhancementsLuke Brennan
This document discusses medically relevant enhancements and proposes a framework to distinguish them from medical treatments. It begins by defining enhancements as interventions that improve human functioning beyond what is necessary for health. However, it notes issues with this definition. The document then proposes an "expected functioning account" to better distinguish enhancements and treatments. Under this framework, a treatment returns a patient to their previous level of functioning, while an enhancement improves functioning beyond that level. The document focuses on "medically relevant enhancements" - those that make people less susceptible to disease without significantly altering other traits. It argues these types of enhancements can permissibly be used in medicine to fight disease.
- Fundamentals of Nursing: history of nursing
- Florence Nightingale
- Nursing & Midwifery Council. (2015). the code: Professional standards of practice and behaviour for nurses and midwives.
- What is Critical Thinking?
- Why is Critical Thinking Important to Nurses?
- Complex thinking
- Important concepts in nursing
- The nursing process: Assessment
o Data collection: Objective & Subjective data
o Methods of Data Collection
Observation
Vital signs
BMI
• How to calculate
• Classification of BMI according to WHO
MAUC
Homeostasis
The interview
Samples
Information from the patient
Glascow scale
Physical examination
• Inspection
• Palpation
• Percussion
• Auscultation
Patient record
o The aims of assessment/rational for conducting a nursing assessment
o Holistic assessment
o Pressure sores
The Water low scale
o Medical history & Nursing history
o The environment during patient assessment
o Asking questions
This study aims to determine if a nurse-delivered discharge planning bundle that includes a follow-up phone call within 1 week of discharge will decrease rapid readmissions of patients with heart failure. The researchers will implement a discharge care bundle including patient education and a follow-up phone call on a hospital unit. They will compare rates of readmission before and after the intervention to see if the bundle reduces readmissions. The goal is to improve patient outcomes and lower healthcare costs for heart failure patients.
Colin Jones presented a case study on his client Eileen, a 68-year-old woman diagnosed with Guillain-Barré syndrome. Eileen was dependent on others for activities of daily living and mobility following her illness. The occupational therapy process included assessments, goal setting to improve independence, and recommending Eileen for rehabilitation. Interventions targeted improving upper limb function and mobility to allow Eileen to return safely to her two-story home.
This research proposal aims to study how strengthening patient-agency, or a patient's ability to manage their own healthcare, can improve outcomes for veterans. The proposal outlines three areas of focus: 1) Developing a standardized method to measure patient-agency in VA settings, 2) Explaining how stressors impact changes in patient-agency over time, and 3) Evaluating how VA programs affect veterans' physical, psychological and economic restoration by changing patient-agency. The goal is to help VA better support veterans' transitions after service by empowering them to direct their own healthcare and treatment.
Hospital-acquired pressure injuries are a significant issue, costing $11 billion annually in the US. A fishbone diagram was used to identify multiple factors that influence pressure injury development, including patient characteristics, materials, staff, processes, environment, and methods. Evidence shows that involving patients in their own care through education on positioning, mobility, and prevention can help reduce injuries. Evaluating prevention strategies and pressure injury rates through staff meetings and assessing staging can help hospitals improve processes and decrease injuries over time.
This document discusses hourly rounding, which involves nurses checking on patients on an hourly basis. It presents national averages for HCAHPS scores and outlines several improved outcomes associated with hourly rounding such as patient satisfaction, safety, and reduced call light usage. The 6P protocol is described which involves greeting the patient and addressing their pain, personal needs, positioning, bathroom needs, and environment. Benefits of hourly rounding include increased HCAHPS scores, hospital reimbursement, and nurse satisfaction and efficiency.
This lecture was given by Dr Rhian Lewis, Consultant in Pain Management from Bangor, North Wales, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. Her lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
www.wspg.org.uk
bioethical considerations for preventative enhancementsLuke Brennan
This document discusses medically relevant enhancements and proposes a framework to distinguish them from medical treatments. It begins by defining enhancements as interventions that improve human functioning beyond what is necessary for health. However, it notes issues with this definition. The document then proposes an "expected functioning account" to better distinguish enhancements and treatments. Under this framework, a treatment returns a patient to their previous level of functioning, while an enhancement improves functioning beyond that level. The document focuses on "medically relevant enhancements" - those that make people less susceptible to disease without significantly altering other traits. It argues these types of enhancements can permissibly be used in medicine to fight disease.
- Fundamentals of Nursing: history of nursing
- Florence Nightingale
- Nursing & Midwifery Council. (2015). the code: Professional standards of practice and behaviour for nurses and midwives.
- What is Critical Thinking?
- Why is Critical Thinking Important to Nurses?
- Complex thinking
- Important concepts in nursing
- The nursing process: Assessment
o Data collection: Objective & Subjective data
o Methods of Data Collection
Observation
Vital signs
BMI
• How to calculate
• Classification of BMI according to WHO
MAUC
Homeostasis
The interview
Samples
Information from the patient
Glascow scale
Physical examination
• Inspection
• Palpation
• Percussion
• Auscultation
Patient record
o The aims of assessment/rational for conducting a nursing assessment
o Holistic assessment
o Pressure sores
The Water low scale
o Medical history & Nursing history
o The environment during patient assessment
o Asking questions
Lisa M. Golightly is a physical therapist with over 8 years of experience working in private practices, home health, and skilled nursing facilities. She has treated patients across the lifespan from pediatrics to geriatrics for various conditions using therapeutic exercises, manual therapy, and modalities. Golightly holds several credentials including her DPT, certifications in athletic training, strength and conditioning, and kinesio taping. She is currently the head PT and clinic manager at Therapy PROS in Menifee, CA where she oversees staff and manages all aspects of patient care.
to encourage nursing professional to provide sound, effective and holistic nursing care to the client by using nursing process. Nursing process is the both heart and brain of the Nursing.
This study assessed long-term outcomes of surgical versus nonsurgical treatment of sciatica caused by a herniated lumbar disc. Over 10 years:
- 69% of surgically treated patients reported improved symptoms versus 61% nonsurgically treated, and 56% of surgical patients reported much better or resolved leg and back pain versus 40% nonsurgical.
- Surgically treated patients also reported greater satisfaction and improved functional status compared to nonsurgical patients, though work disability outcomes were similar between groups.
- By 10 years, 25% of each group had additional lumbar spine surgeries, though surgical patients initially had worse symptoms and findings.
This document discusses hourly rounding, a quality improvement project to improve patient satisfaction and outcomes. It describes who can perform hourly rounding, which involves assessing patients' pain, bathroom needs, possessions, mobility, and other needs every hour. Studies show hourly rounding can increase patient satisfaction scores, decrease call light usage and falls, and improve the work of nurses and other staff. Proper staff training and support is needed to successfully implement hourly rounding.
This document provides a performance appraisal for Dr. Zamfirova, an internal medicine physician. It summarizes research on different methods used to evaluate physician performance, including appointment length, clinical performance assessments using composite measures, a physician's capacity for change, and compensation based on RVUs. The research presented acknowledges there are many factors that influence performance evaluations and no single measure can accurately capture a physician's overall quality of care.
The document discusses the nursing process and its introduction, definition, steps, and importance. It provides a brief history of the development of the nursing process from the 1950s to the present. The key steps discussed in detail include assessment, nursing diagnosis, planning, implementation, and evaluation. The nursing process is presented as a systematic, problem-solving approach that directs nursing activities and provides quality nursing care.
The Nursing Process enables nurses to systematically organize and deliver patient care by assessing patients, diagnosing issues, planning and implementing interventions, and evaluating outcomes in a continuous and cyclic manner. It involves collecting both subjective and objective data to understand a patient's health issues and needs in order to establish individualized plans and deliver targeted nursing care. The ultimate goals of the Nursing Process are to identify and address any actual or potential health problems patients may have.
This document provides biographical and professional information about Tiffanie Pierce, MSN, RN, CNP. It includes her education history, which consists of various nursing degrees from institutions such as Saint Louis University and Miami University. Her experience section outlines her work as a family nurse practitioner and registered nurse in pediatric, orthopedic, and emergency room settings at hospitals like Cincinnati Children's Hospital Medical Center and Atrium Medical Center. She has also published papers and presented on topics related to postoperative pain management in pediatric patients.
The document outlines the nursing process, which includes 5 phases - assessment, nursing diagnosis, planning, implementation, and evaluation.
The assessment phase involves collecting client data through various methods like observation, interview, and examination. In the nursing diagnosis phase, the nurse analyzes the assessment data to identify client problems/needs and prioritize them.
The planning phase involves setting goals to address the problems and selecting nursing interventions. Implementation involves applying the planned care. Finally, in the evaluation phase the nurse determines if the goals were met by collecting additional client data. The nursing process provides a systematic framework to plan and deliver individualized nursing care.
1) Two hospitals implemented regular hourly rounding programs to improve patient experience.
2) Rounding involves checking on patients' needs, pain levels, comfort and safety every 1-2 hours.
3) Early results show reductions in falls and improvements in HCAHPS scores for nursing communication and responsiveness.
The series of questions provided would likely occur during the "Gathering information about the patient's chief concerns" phase of a patient-centered interview. The questions are gathering specific details about the patient's diet and weight, which are important concerns to assess. Setting the stage would involve introducing oneself and explaining the purpose of the interview. Collecting the assessment involves gathering additional assessment data through physical exam or tests. Termination involves concluding the interview.
The document discusses nursing diagnosis. It begins by defining nursing diagnosis as a clinical judgment about an individual's response to actual or potential health problems. Nursing diagnosis provides the basis for selecting nursing interventions. The document then discusses the purpose of nursing diagnosis, how it is developed and classified. It compares nursing diagnosis to medical diagnosis and outlines the components and process of developing a nursing diagnostic statement.
Deterioration of a patient can occur at any time in the patient’s journey and eventually they may need critical care intervention or worse. Hear about NHS Ayrshire & Arran’s rescue system and how their model for improvement was used to design, implement and sustain reliable care processes that facilitated a reduction in mortality rates.
This document discusses clinical decision making in physical therapy. It covers evaluating a patient through examination, determining a diagnosis, establishing a prognosis and plan of care, implementing interventions, and assessing outcomes. Key parts of the examination process are gathering a health history, performing systems reviews, and using specific tests and measures. The evaluation involves analyzing collected data to interpret a patient's condition. Evidence-based practice and a patient management model guide clinical decisions. Motor learning principles also inform effective exercise instruction and functional training.
This document defines nursing diagnosis and discusses its key components and characteristics. A nursing diagnosis is a clinical judgment about an individual's response to an actual or potential health problem. It includes a diagnostic label, qualifiers, definition, defining characteristics, and risk factors. There are several types of nursing diagnoses, including actual, risk, possible, wellness, and syndrome diagnoses. The document outlines the Process-Etiology-Signs/Symptoms (PES) structure for formulating nursing diagnoses and provides examples of different diagnosis structures.
The document outlines the nursing process and provides details on each step: assessment, nursing diagnosis, planning, implementation, and evaluation. It describes how nurses analyze patient data to formulate nursing diagnoses and identify goals and interventions. The planning stage involves prioritizing issues and developing individualized care plans. Implementation entails performing or delegating interventions. Evaluation assesses progress towards goals and the effectiveness of the care plan.
1) This randomized controlled trial compared care provided by nurse practitioners to care provided by general practitioners for 1,368 patients requesting same-day consultations across 10 general practices.
2) Results found that patients consulting with nurse practitioners reported higher satisfaction with their care, though for adults this difference was not observed in all practices. Consultations with nurse practitioners were also significantly longer.
3) In terms of clinical outcomes like resolution of symptoms, prescriptions issued, investigations ordered, and referrals, there was no significant difference between care provided by nurse practitioners versus general practitioners.
4) The study supports the role of nurse practitioners in providing care to patients requesting same-day consultations in primary care. Nurse
The document discusses innovations in chronic disease management within primary care practices. It introduces the Chronic Care Model, which identifies six essential elements for improving chronic illness care: community resources, health care organization, self-management support, delivery system design, decision support, and clinical information systems. The model predicts that enhancing these six interrelated components can produce higher quality chronic care, with informed, proactive patients interacting with well-prepared practice teams. The article then provides case studies of four health care organizations that have implemented aspects of the Chronic Care Model, leading to improved chronic disease outcomes in their patient populations.
Stephen Radley Consultant Obstetrician & Gynaecologist3GDR
This document discusses the benefits and practicalities of setting up and running virtual clinics. It provides an overview of virtual clinics and how they can utilize different communication methods like the internet to provide remote medical care. It then describes how the presenter has set up virtual urogynaecology clinics using an electronic pelvic floor questionnaire (ePAQ) to collect patient data before appointments. Patients found the virtual approach eased disclosure of sensitive issues and clinicians saw benefits like embedded outcomes tracking. The presentation concludes by discussing lessons learned and the practical steps involved in implementing a virtual clinic.
The EMR module allows users to enter patient discharge details including medical history, treatment details, and instructions for home care. Users can search for and view admitted and discharged patient information, then enter details of the patient's discharge medications, instructions, and surgical site care. The module generates discharge reports that can be printed for patients.
Lisa M. Golightly is a physical therapist with over 8 years of experience working in private practices, home health, and skilled nursing facilities. She has treated patients across the lifespan from pediatrics to geriatrics for various conditions using therapeutic exercises, manual therapy, and modalities. Golightly holds several credentials including her DPT, certifications in athletic training, strength and conditioning, and kinesio taping. She is currently the head PT and clinic manager at Therapy PROS in Menifee, CA where she oversees staff and manages all aspects of patient care.
to encourage nursing professional to provide sound, effective and holistic nursing care to the client by using nursing process. Nursing process is the both heart and brain of the Nursing.
This study assessed long-term outcomes of surgical versus nonsurgical treatment of sciatica caused by a herniated lumbar disc. Over 10 years:
- 69% of surgically treated patients reported improved symptoms versus 61% nonsurgically treated, and 56% of surgical patients reported much better or resolved leg and back pain versus 40% nonsurgical.
- Surgically treated patients also reported greater satisfaction and improved functional status compared to nonsurgical patients, though work disability outcomes were similar between groups.
- By 10 years, 25% of each group had additional lumbar spine surgeries, though surgical patients initially had worse symptoms and findings.
This document discusses hourly rounding, a quality improvement project to improve patient satisfaction and outcomes. It describes who can perform hourly rounding, which involves assessing patients' pain, bathroom needs, possessions, mobility, and other needs every hour. Studies show hourly rounding can increase patient satisfaction scores, decrease call light usage and falls, and improve the work of nurses and other staff. Proper staff training and support is needed to successfully implement hourly rounding.
This document provides a performance appraisal for Dr. Zamfirova, an internal medicine physician. It summarizes research on different methods used to evaluate physician performance, including appointment length, clinical performance assessments using composite measures, a physician's capacity for change, and compensation based on RVUs. The research presented acknowledges there are many factors that influence performance evaluations and no single measure can accurately capture a physician's overall quality of care.
The document discusses the nursing process and its introduction, definition, steps, and importance. It provides a brief history of the development of the nursing process from the 1950s to the present. The key steps discussed in detail include assessment, nursing diagnosis, planning, implementation, and evaluation. The nursing process is presented as a systematic, problem-solving approach that directs nursing activities and provides quality nursing care.
The Nursing Process enables nurses to systematically organize and deliver patient care by assessing patients, diagnosing issues, planning and implementing interventions, and evaluating outcomes in a continuous and cyclic manner. It involves collecting both subjective and objective data to understand a patient's health issues and needs in order to establish individualized plans and deliver targeted nursing care. The ultimate goals of the Nursing Process are to identify and address any actual or potential health problems patients may have.
This document provides biographical and professional information about Tiffanie Pierce, MSN, RN, CNP. It includes her education history, which consists of various nursing degrees from institutions such as Saint Louis University and Miami University. Her experience section outlines her work as a family nurse practitioner and registered nurse in pediatric, orthopedic, and emergency room settings at hospitals like Cincinnati Children's Hospital Medical Center and Atrium Medical Center. She has also published papers and presented on topics related to postoperative pain management in pediatric patients.
The document outlines the nursing process, which includes 5 phases - assessment, nursing diagnosis, planning, implementation, and evaluation.
The assessment phase involves collecting client data through various methods like observation, interview, and examination. In the nursing diagnosis phase, the nurse analyzes the assessment data to identify client problems/needs and prioritize them.
The planning phase involves setting goals to address the problems and selecting nursing interventions. Implementation involves applying the planned care. Finally, in the evaluation phase the nurse determines if the goals were met by collecting additional client data. The nursing process provides a systematic framework to plan and deliver individualized nursing care.
1) Two hospitals implemented regular hourly rounding programs to improve patient experience.
2) Rounding involves checking on patients' needs, pain levels, comfort and safety every 1-2 hours.
3) Early results show reductions in falls and improvements in HCAHPS scores for nursing communication and responsiveness.
The series of questions provided would likely occur during the "Gathering information about the patient's chief concerns" phase of a patient-centered interview. The questions are gathering specific details about the patient's diet and weight, which are important concerns to assess. Setting the stage would involve introducing oneself and explaining the purpose of the interview. Collecting the assessment involves gathering additional assessment data through physical exam or tests. Termination involves concluding the interview.
The document discusses nursing diagnosis. It begins by defining nursing diagnosis as a clinical judgment about an individual's response to actual or potential health problems. Nursing diagnosis provides the basis for selecting nursing interventions. The document then discusses the purpose of nursing diagnosis, how it is developed and classified. It compares nursing diagnosis to medical diagnosis and outlines the components and process of developing a nursing diagnostic statement.
Deterioration of a patient can occur at any time in the patient’s journey and eventually they may need critical care intervention or worse. Hear about NHS Ayrshire & Arran’s rescue system and how their model for improvement was used to design, implement and sustain reliable care processes that facilitated a reduction in mortality rates.
This document discusses clinical decision making in physical therapy. It covers evaluating a patient through examination, determining a diagnosis, establishing a prognosis and plan of care, implementing interventions, and assessing outcomes. Key parts of the examination process are gathering a health history, performing systems reviews, and using specific tests and measures. The evaluation involves analyzing collected data to interpret a patient's condition. Evidence-based practice and a patient management model guide clinical decisions. Motor learning principles also inform effective exercise instruction and functional training.
This document defines nursing diagnosis and discusses its key components and characteristics. A nursing diagnosis is a clinical judgment about an individual's response to an actual or potential health problem. It includes a diagnostic label, qualifiers, definition, defining characteristics, and risk factors. There are several types of nursing diagnoses, including actual, risk, possible, wellness, and syndrome diagnoses. The document outlines the Process-Etiology-Signs/Symptoms (PES) structure for formulating nursing diagnoses and provides examples of different diagnosis structures.
The document outlines the nursing process and provides details on each step: assessment, nursing diagnosis, planning, implementation, and evaluation. It describes how nurses analyze patient data to formulate nursing diagnoses and identify goals and interventions. The planning stage involves prioritizing issues and developing individualized care plans. Implementation entails performing or delegating interventions. Evaluation assesses progress towards goals and the effectiveness of the care plan.
1) This randomized controlled trial compared care provided by nurse practitioners to care provided by general practitioners for 1,368 patients requesting same-day consultations across 10 general practices.
2) Results found that patients consulting with nurse practitioners reported higher satisfaction with their care, though for adults this difference was not observed in all practices. Consultations with nurse practitioners were also significantly longer.
3) In terms of clinical outcomes like resolution of symptoms, prescriptions issued, investigations ordered, and referrals, there was no significant difference between care provided by nurse practitioners versus general practitioners.
4) The study supports the role of nurse practitioners in providing care to patients requesting same-day consultations in primary care. Nurse
The document discusses innovations in chronic disease management within primary care practices. It introduces the Chronic Care Model, which identifies six essential elements for improving chronic illness care: community resources, health care organization, self-management support, delivery system design, decision support, and clinical information systems. The model predicts that enhancing these six interrelated components can produce higher quality chronic care, with informed, proactive patients interacting with well-prepared practice teams. The article then provides case studies of four health care organizations that have implemented aspects of the Chronic Care Model, leading to improved chronic disease outcomes in their patient populations.
Stephen Radley Consultant Obstetrician & Gynaecologist3GDR
This document discusses the benefits and practicalities of setting up and running virtual clinics. It provides an overview of virtual clinics and how they can utilize different communication methods like the internet to provide remote medical care. It then describes how the presenter has set up virtual urogynaecology clinics using an electronic pelvic floor questionnaire (ePAQ) to collect patient data before appointments. Patients found the virtual approach eased disclosure of sensitive issues and clinicians saw benefits like embedded outcomes tracking. The presentation concludes by discussing lessons learned and the practical steps involved in implementing a virtual clinic.
The EMR module allows users to enter patient discharge details including medical history, treatment details, and instructions for home care. Users can search for and view admitted and discharged patient information, then enter details of the patient's discharge medications, instructions, and surgical site care. The module generates discharge reports that can be printed for patients.
Improving Timeliness and Quality: Discharge Summaries Dictated by Internal Me...emallin
The document discusses improving the timeliness and quality of discharge summaries dictated by internal medicine residents. It describes challenges with current discharge summaries and studies showing delays in availability and poor quality can contribute to adverse events. An educational intervention was instituted along with a same-day discharge process, which improved the timeliness of discharge summaries without compromising quality. Preliminary results also showed the educational intervention improved completeness scores of discharge summaries, though not statistically significantly, and did not affect readability.
This document introduces eCare, an inpatient discharge summary application that allows clinicians to electronically record a patient's diagnosis, treatment, prescriptions, and follow-up notes. The application aims to improve communication with general practitioners by transmitting summaries within 72 hours of discharge. It also seeks to enhance accuracy of clinical coding and prescribed medications through real-time documentation. A pilot program will test the software with a small number of consultants over 1-2 months before full review and potential further development.
This document contains an orthopedic physiotherapy quiz with 50 multiple choice questions covering various topics in orthopedics and physiotherapy. Some of the questions assess knowledge of common orthopedic conditions, treatments, tests, and complications. Other questions require identification of muscles, bones, diseases, and physiotherapy approaches. The quiz covers a wide range of topics to evaluate understanding of orthopedic and musculoskeletal physiotherapy.
The document discusses improving the discharge process at KIMS hospital. It finds that the average discharge times are 3 hours 10 minutes for cash patients, 4 hours 2 minutes for credit patients, and 7 hours for insurance patients. A patient satisfaction survey found 33.5% of patients were under satisfied with the discharge process. The document analyzes the major causes of delay and provides suggestions to standardize processes and reduce discharge times, including having doctors type discharge summaries, centralizing pharmacy clearance, and improving communication between departments through the hospital information management system. Faster discharge times could increase hospital capacity and profitability.
This document discusses implementing electronic medication reconciliation (eMR) to improve patient safety during transitions of care. eMR embeds the medication reconciliation process within electronic systems used at admission, transfer, and discharge. Pilot programs at two District Health Boards saw improvements like fewer medication errors and increased accuracy and completeness of medication information. Challenges included engaging doctors and changes to workflows. Ongoing efforts are needed for regional clinical information sharing and electronic prescribing across care settings.
- Lawrence Weed first described the concept of electronic medical records in the 1960s as a way to automate and organize patient records to improve care. Early systems like POMR were developed in the 1970s and refined in later decades.
- Today, most medical practices use electronic systems to record patient information like medical history, medications, test results, and billing data. Adoption has increased but fewer than half of physicians fully utilize digital records.
- Benefits include increased efficiency, reduced errors, better access to information, and potential financial incentives. Challenges include costs of implementation and use, user resistance, and privacy concerns over confidential patient data.
Overview of Electronic Medical Records - Sanjoy SanyalSanjoy Sanyal
Gives an overview of Electronic Medical Records (EMR) / Electronic Health records (EHR) / Patient Health records (PHR), with company screenshots and specialty specific EMR examples. Presented at a seminar in Seychelles in 2008.
Very useful for Informatics professional, Medical professionals, Healthcare administrators. This is a constantly evolving issue, and some things mentioned here may have undergone modification since the time of their original publication.
Tags: emr, mapping engine, Electronic Medical Record, EMR, Electronic Health record, HER, Patient Health record, PHR, Sanjoy Sanyal,
This document discusses the benefits and challenges of electronic health records (EHRs) and their role in public health informatics. It outlines how EHRs can improve patient care by providing more legible, shareable records compared to paper charts. EHRs also enable clinical decision support, alerts, and reminders to help practitioners. On a larger scale, EHR data in clinical data repositories and registries can help public health by tracking diseases, exposures, and procedures. However, EHR adoption faces challenges such as costs, technical issues, security concerns, and lack of standardized data exchange. Overall, the document argues that EHRs have the potential to dramatically change clinical practice and safeguard populations through improved teamwork and surveillance
This document discusses Community Health Connections' implementation of an electronic health record system. It provides an overview of the organization and outlines their plan to implement OpenVista EHR software across three clinics by February 2011. It describes the anticipated benefits of EHR including reduced errors, improved workflows and access to patient information. The implementation plan includes teams for project management, hardware, software and stakeholders. It also covers training, data migration, technical infrastructure including servers and network upgrades, meeting meaningful use requirements and realizing financial benefits and savings.
Powerpoint on electronic health record lab 1nephrology193
This presentation provides an overview of electronic health records (EHR). It defines EHR as a digital format for documenting a patient's medical history maintained by healthcare providers. EHR files contain sections for different types of health information. The presentation outlines benefits of EHR such as reducing medical errors, improving quality of care through better disease management and education, and decreasing healthcare costs. It also discusses how EHR protects patient privacy through security measures and restrictions on who can access records.
The presentation describes in brief the patients need, expectations and how to develop the patient care and feedback system to obtain maximum patient satisfaction.
This document discusses the implementation of electronic medical records (EMR). It outlines reasons to implement EMR, such as reducing medical errors from illegible handwriting and inaccurate abbreviations. The implementation process involves choosing software and a vendor, testing, and training. There are costs for equipment, lawsuits, and unnecessary medical procedures that EMR can reduce. EMR also allows for faster treatment decisions and easier transfer of patient information. While costly initially, EMR provides long-term financial benefits and improves patient healthcare overall.
Role of hospital pharmacists in transitions of careRosalynn Pangan
Hospital pharmacists play a key role in medication reconciliation during care transitions to reduce medication errors. Medication reconciliation involves creating an accurate list of all medications a patient is taking and reconciling it with physician orders at various transition points like admission, transfer, and discharge. Studies show high rates of unintentional medication discrepancies during transitions that can harm patients if undetected. Pharmacists conducting medication reconciliation at transitions have been shown to identify and resolve many discrepancies, intercepting potential errors. Key elements for successful reconciliation include designating a single list shared by all providers, clearly defining roles, integrating the process into workflow, educating patients, and conducting reconciliation at various transition points in the care process.
An emergency department quality improvement projectyasmeenzulfiqar
The document discusses improving vital sign documentation during triage in emergency departments. It aims to investigate factors affecting vital sign data quality during measurement and documentation, and provide recommendations for improvement. A literature review found that timely and accurate vital sign documentation is important for identifying deteriorating patients. However, studies on nursing workflows and documentation of vital signs are limited. The objective is to study nurses' vital sign documentation process through a questionnaire of nurses and analysis of the data. Results showed teamwork and quality improvement efforts like education and training can enhance compliance with vital sign documentation standards during triage. Recommendations include departments addressing challenges in measurement time and reviewing results to improve performance.
This qualitative systematic review synthesized 77 papers reporting on 60 studies to understand patients' experiences of chronic non-malignant musculoskeletal pain. The key finding was that patients experience chronic pain as an adversarial struggle on multiple levels, including affirming their identity, reconstructing their identity over time, explaining their suffering, navigating the healthcare system, and proving the legitimacy of their pain. However, some patients also expressed a sense of moving forward alongside their pain. The review provides insight for improving the patient experience by better understanding their pain and forming collaborative partnerships to help patients manage their condition.
1) The document discusses the importance of developing core outcome sets (COS) for clinical trials through consensus processes that meaningfully incorporate input from patients. COS ensure consistency across trials by specifying a minimum set of outcomes to measure.
2) Involving patients in determining what health outcomes to measure in COS is crucial because patients can identify which outcomes have the greatest impact on their lives. Their input also helps prevent selective reporting of outcomes in trials.
3) Developing COS through consensus processes that engage patients, healthcare providers, and other stakeholders from the beginning can launch trials with outcomes relevant to all groups. This maximizes the usefulness of research data.
This document discusses using patient-reported outcomes (PROs) to measure healthcare quality from the patient's perspective. It argues that PROs capture patients' experiences with illness, impairment, and disability, which is important because patients seek healthcare to improve their ability to function and reduce symptoms. The document also notes that treatments may improve clinical markers but not subjective patient outcomes. It advocates routinely collecting PRO data electronically to develop new performance metrics focused on whether treatments actually improve how patients feel and function. This would help align healthcare with how patients define quality.
This document describes research to develop a set of proposed patient perspective domains or headings to capture patients' experiences of living with long-term health conditions. The researchers engaged patients, carers, and professionals through workshops and an online survey to understand which issues were important to patients. An initial set of 11 draft headings were developed based on the WHO International Classification of Functioning and refined through consultation. The final results identified key themes important to representing patient perspectives in care planning.
The document discusses the role of physical therapists in patient/client management. It describes the five key elements of patient management as examination, evaluation, diagnosis, prognosis, and intervention. Evaluation involves creating a problem list for the patient. Diagnosis categorizes the problems into defined clusters or syndromes. Prognosis predicts the patient's expected improvement, timeline, and outcomes. Discharge and discontinuation processes determine when physical therapy services are concluded. Outcomes analyze the overall impact of interventions on the patient.
Real effectiveness medicine pursuing best effectiveness in the ordinary care ...Malmivaara Antti
These slides present a new concept of Real-Effectiveness Medicine (REM), which pursues the best effectiveness of patient care in the real-world setting. In order to reach the goal, four layers of information are needed: 1) expertise or the health care personnel, 2) use of up-to-date scientific evidence, 3) continuous documentation of performance and quality improvement, and 4) benchmarking between providers. The new framework is suggested for clinicians, organizations, policy-makers, and researchers.
04- PT as a Patient Client manager.pptxChangezKhan33
In this lecture role of PT is defined and explained as a patient client manager, how he or she uses his or her knowledge for the betterment of patient symptoms and history.
This document summarizes a session at the 2015 CADTH conference on engaging patients in defining value and drug development. It provides an overview of the session which included panels discussing defining value from the patient perspective and models of patient engagement. It also summarizes some of the key points discussed, such as the need to include patient perspectives throughout the drug development process to better measure what is meaningful to patients and alternative approaches to patient engagement like patient and community engagement researchers. The document advocates that embedding meaningful patient measures can help weight evidence from the patient perspective.
113DNP Prospectus Comment by Cynthia Fletcher Th.docxherminaprocter
1
13
DNP Prospectus Comment by Cynthia Fletcher: This is a good beginning Ann Marie. There are many areas that we will discuss at our meeting to improve clarity and congruence with a DNP Project.
Educating Inpatient Nurses to use Standardized Care Plans
Anne Marie Wouapet
Doctor of Nursing Practice – Nursing Informatics
A00505587
Prospectus: Educating Inpatient Nurses to use Standardized Care Plans
Problem Statement
Standardized care plans can be described as the pre-determined menu of interventions which are used for different patient situations (Monsen, Swenson & Kerr, 2016). Evidence-based care is the conscientious use of the most recent evidence to make decisions on the care of individual patients or in the delivery of health care services (Murdaugh, Parsons & Pender, 2018). The current best evidence is the most recent information which has been obtained from valid and relevant research about the effects of different types of healthcare, the accuracy of diagnostic tests, the potential for harm from exposure to different agents, or predictive power of prognostic factor (Schmidt & Brown, 2017). Standardized care plans form the main basis for the implementation of evidence-based care directly in practice and for the improvement of patient outcomes (Nussbaum et al., 2015; Yehuda & Hoge, 2016). A health care facility recently transitioned to the use of a new and better electronic health record system. The facility also purchased standardized care plans to increase efficiency in their operations. However, the compliance with using the standardized care plans was only 40 percent among the inpatient nurses. Comment by Cynthia Fletcher: ?Comment by Cynthia Fletcher: Questionable purpose.Comment by Cynthia Fletcher: Was it different for those who were not inpatient nurses?
Accordingly, the facility recently had a visit from the Joint Commission on Accreditation of Healthcare Organizations and received a negative rating because the nurses were not adding care plans based on the patients' primary problem or diagnosis in the patients' charts upon admission. This presents several specific problems in the healthcare facility. There is poor compliance from the nurses concerning the addition of standardized care plans to the charts of patients based on their diagnosis or primary problem(s). The system which the facility invested in was not being used for the improvement of patient outcomes and quality of care delivered. The focus of this project is the failure of inpatient nurses to make use of standardized care plans. The gap in nursing is the failure of delivery of evidence-based practice using the standardized care plans which result in poor patient outcomes and quality of life. One of the areas of knowledge that has not yet been explored is the cause of low rates of adoption of standardized care plans by nurses. Another gap is the lack of studies on nurses’ perception of the standardized care plans and how they affect their use in .
The document discusses various ways to evaluate the effectiveness of advanced practice nurses (APNs) through research. It notes that while some early research found APNs provided safe, effective, and cost-efficient care, more ongoing research is still needed. Specifically, more documentation is required on APN contributions, outcomes, quality of care provided, and how APNs work with other healthcare providers.
Outcomes research tests evidence-based interventions to see how they impact individuals, groups, and populations. It examines the effects on both patients and healthcare providers. The Patient Protection and Affordable Care Act, Accountable Care Organizations, Center for Medicare and Medicaid Services, Agency for Healthcare Research and Quality, and Patient Centered Outcomes Research Institute all play roles in outcomes research. Outcomes research can help improve patient care by identifying effective interventions and understanding different treatment outcomes. However, outcomes may differ based on patient demographics and reported data could be skewed.
The Use of Health Information Technology to Improve Care and .docxpelise1
The Use of Health Information Technology to Improve Care and
Outcomes for Older Adults
Kathryn H. Bowles, PhD, FAAN, FACMI,
van Ameringen Professor in Nursing Excellence, Director of the Center for Integrative Science in
Aging, University of Pennsylvania School of Nursing, Philadelphia, PA
Patricia Dykes, PhD, FAAN, FACMI, and
Senior Nurse Scientist, Director of the Center for Patient Safety Research and Practice; Director
of the Center for Nursing Excellence, Brigham and Women’s Hospital, Boston, MA
George Demiris, PhD, FACMI
Alumni Endowed Professor in Nursing; Professor in Biomedical and Health Informatics, School of
Medicine; Director, Clinical Informatics and Patient Centered Technologies; Graduate Program
Director, Biomedical and Health Informatics University of Washington, Seattle, Washington
Introduction
Using health information technology (HIT) to improve care and outcomes for older adults is
a growing program of research propelled by recent transformative policies such as the
Health Information Technology for Economic and Clinical Health (HITECH) Act
(Blumenthal, 2010; Institute of Medicine, 2011) and the Institute of Medicine report, "The
Future of Nursing: Leading Change, Advancing Health." (Institute of Medicine, 2010). Both
documents call for the implementation of electronic health records (EHR) and HIT solutions
to improve the safety, quality and efficiency of care. Several nurse scientists are at the
forefront of advancing this work, particularly using electronic health records, decision
support and telehealth. This commentary highlights examples of recent research (2010–
2014) led by nurse scientists using HIT to improve patient safety, and the quality and
efficiency of patient care. We also discuss future opportunities for Gerontological nurse
scientists interested in blending the care of older adults and HIT and suggest strategies to
increase our capacity to engage in such innovative research.
Using the EHR to improve outcomes for older adults
Recent incentives provided by the HITECH Act have resulted in rapid growth in the
development and implementation of the EHR. Nurse led studies are beginning to
demonstrate that effective use of the EHR can improve outcomes of relevance to older
adults such as pressure ulcers and falls. Dowding and colleagues evaluated the impact of an
integrated EHR in 29 Kaiser Permanente hospitals on process and outcome indicators for
patient falls and hospital acquired pressure ulcers (Dowding, Turley, & Garrido, 2012).
They found that the EHR system was associated with improved documentation of both fall
and pressure ulcer risk assessments and statistically significant improvements for pressure
ulcer risk assessment documentation. They demonstrated that improved documentation
using the EHR was associated with a 13% decrease in hospital acquired pressure ulcer rates.
HHS Public Access
Author manuscript
Res Gerontol Nurs. Author manuscript; avai.
Chapter 4 Knowledge Discovery, Data Mining, and Practice-Based Evi.docxchristinemaritza
Chapter 4 Knowledge Discovery, Data Mining, and Practice-Based Evidence
Mollie R. Cummins
Ginette A. Pepper
Susan D. Horn
The next step to comparative effectiveness research is to conduct more prospective large-scale observational cohort studies with the rigor described here for knowledge discovery and data mining (KDDM) and practice-based evidence (PBE) studies.
Objectives
At the completion of this chapter the reader will be prepared to:
1.Define the goals and processes employed in knowledge discovery and data mining (KDDM) and practice-based evidence (PBE) designs
2.Analyze the strengths and weaknesses of observational designs in general and of KDDM and PBE specifically
3.Identify the roles and activities of the informatics specialist in KDDM and PBE in healthcare environments
Key Terms
Comparative effectiveness research, 69
Confusion matrix, 62
Data mining, 61
Knowledge discovery and data mining (KDDM), 56
Machine learning, 56
Natural language processing (NLP), 58
Practice-based evidence (PBE), 56
Preprocessing, 56
Abstract
The advent of the electronic health record (EHR) and other large electronic datasets has revolutionized efficient access to comprehensive data across large numbers of patients and the concomitant capacity to detect subtle patterns in these data even with missing or less than optimal data quality. This chapter introduces two approaches to knowledge building from clinical data: (1) knowledge discovery and data mining (KDDM) and (2) practice-based evidence (PBE). The use of machine learning methods in retrospective analysis of routinely collected clinical data characterizes KDDM. KDDM enables us to efficiently and effectively analyze large amounts of data and develop clinical knowledge models for decision support. PBE integrates health information technology (health IT) products with cohort identification, prospective data collection, and extensive front-line clinician and patient input for comparative effectiveness research. PBE can uncover best practices and combinations of treatments for specific types of patients while achieving many of the presumed advantages of randomized controlled trials (RCTs).
Introduction
Leaders need to foster a shared learning culture for improving healthcare. This extends beyond the local department or institution to a value for creating generalizable knowledge to improve care worldwide. Sound, rigorous methods are needed by researchers and health professionals to create this knowledge and address practical questions about risks, benefits, and costs of interventions as they occur in actual clinical practice. Typical questions are as follows:
•Are treatments used in daily practice associated with intended outcomes?
•Can we predict adverse events in time to prevent or ameliorate them?
•What treatments work best for which patients?
•With limited financial resources, what are the best interventions to use for specific types of patients?
•What types of indi ...
This summarizes the outcomes of a 6-month pharmacist-provided diabetes management program for employees of the City of Toledo. The program showed improvements in clinical outcomes like A1c and blood pressure. It also improved humanistic outcomes such as patient satisfaction, knowledge, and adherence. Economic outcomes like healthcare utilization and costs improved as well, with a 62.69% reduction in total costs. The study demonstrates positive short-term outcomes across clinical, humanistic and economic domains from a pharmacist-led diabetes management program.
This document lists publications by Ari Gnanasakthy related to patient-reported outcomes in clinical trials and health economics evaluations. It includes 22 publications ranging from 2005 to 2010 related to establishing minimally important differences in patient-reported outcomes, developing guidance for collecting patient-reported data, evaluating the cost-effectiveness of drugs like valsartan and rivastigmine, and methods for conducting economic evaluations alongside multinational clinical trials. The publications indicate Gnanasakthy has extensive experience in analyzing patient-reported outcomes and health economics data from clinical trials.
This document summarizes a transitional care workgroup meeting held on July 12, 2013. The meeting included introductions and presentations on transitional care evidence and measuring patient-centered outcomes. Participants discussed a vignette about a patient being discharged from the hospital to identify questions patients would have about participating in a new transitional care program. The group's objectives were to understand transitional care broadly and narrow the topic by prioritizing important questions from multiple stakeholder perspectives. Breakout sessions allowed for submitted questions and discussion of proposed research topics. The meeting concluded with recapping next steps and welcoming further input.
RESEARCH ARTICLE Open AccessHealthcare professionals’ view.docxrgladys1
RESEARCH ARTICLE Open Access
Healthcare professionals’ views on patient-
centered care in hospitals
Mathilde Berghout*, Job van Exel, Laszlo Leensvaart and Jane M. Cramm*
Abstract
Background: Patient-centered care (PCC) is a main determinant of care quality. Research has shown that PCC is a
multi-dimensional concept, and organizations that provide PCC well report better patient and organizational
outcomes. However, little is known about the relative importance of PCC dimensions. The aim of this study was
therefore to investigate the relative importance of the eight dimensions of PCC according to hospital-based
healthcare professionals, and examine whether their viewpoints are determined by context.
Methods: Thirty-four healthcare professionals (16 from the geriatrics department, 15 from a surgical intensive care
unit, 3 quality employees) working at a large teaching hospital in New York City were interviewed using Q
methodology. Participants were asked to rank 35 statements representing eight dimensions of PCC extracted from
the literature: patient preferences, physical comfort, coordination of care, emotional support, access to care,
continuity and transition, information and education and family and friends. By-person factor analysis was used to
reveal patterns of communality in statement rankings, which were interpreted and described as distinct viewpoints.
Results: Three main viewpoints on elements important for PCC were identified: “treating patients with dignity and
respect,” “an interdisciplinary approach” and “equal access and good outcomes.” In these viewpoints, not all dimensions
were equally important for PCC. Furthermore, the relative importance of the dimensions differed between departments.
Context thus appeared to affect the relative importance of PCC dimensions.
Conclusion: Healthcare organizations wishing to improve PCC should consider the relative importance of
PCC dimensions in their specific context of care provision, which may help to improve levels of patient-
centeredness in a more efficient and focused manner. However, as the study sample is not representative
and consisted only of professionals (not patients), the results cannot be generalized outside the sample.
More research is needed to confirm our study findings.
Keywords: Patient-centered care, Quality of care, Healthcare professionals, Q methodology, Hospital
Background
Since the Institute of Medicine described patient-
centered care (PCC) as one of the six most important
determinants of quality of care – along with safe, effect-
ive, timely, efficient and equitable care – PCC has re-
ceived much more attention [1]. Richardson and
colleagues [1] defined PCC as care that is “respectful of
and responsive to individual patient preferences, needs,
and values, and ensuring that patient values guide all
clinical decisions.” PCC has been shown to result in im-
proved health outcomes, including survival, greater
patient satisfaction and well-being [2]. Furtherm.
Diabetic Care
Lanetra Evans-Shelton
Walden University
Nursing 6052- Dr. Smith
Essentials of Evidence-Based Practice
Diabetic Care
Introduction
The organization I am affiliated with is a correctional facility. It houses over 300 detainees with some being newly diagnosed diabetics. The officers need training because the facility doesn’t have 24-hour nursing and they are responsible for letting the detainees check their blood sugar levels at night and providing snacks. There is increasing interest in quality improvement strategies to improve diabetic management.
The purpose is to provide ongoing preventive care through new activities which will allow us to identify and interfere in the advancement of diabetes while in jail.
The current problem is over half the time the nurses are unaware of the people who have diabetes unless they puts in a medical request which sometimes takes days. The jail has an intake process of getting booked into jail but does not have a medical intake process. And that’s a big change that needs to happen. The stakeholders who needs to be part of the design and implementation for it to make a difference are the quorum courts, the Sherriff, and the Jail’s Chief Administrator. The risk associated with the change is jail administration have no standard strategies to follow when implementing something new..
Proposal
Patients with a diagnosis of diabetes should have a complete medical history and physical examination by a licensed health care team member in a timely manner. Goals should be individualized depending on the situation. This should be documented in the patient's record and communicated to all persons involved in his/her care, including security staff.
The necessity of the change must be acknowledged and acceptable. Staff must be trained for the new procedures. A training curriculum must explain the role, its technical procedures, its strengths and weaknesses, legal requirements, and professional relationship standards. The success of this project prompts conversation with the major, chief and the sheriff. With the organizational adaption and staff involvement the implementation of the change should be successful (Melnyk & Fineout-Overholt, 2018).
People with diabetes should obtain care that meets national standards. Being incarcerated does not change these standards. Patients must have right to medication and nutrition needs to manage their disease. In patients who do not meet treatment goals, medical and behavioral plans should be adjusted by health care providers in collaboration with the prison staff (Worswick, Wayne, Bennett, Fiander, Mayhew, Weir, & Grimshaw, 2013).
It is critical for correctional facilities to identify patients in need of more intensive evaluation and therapy, including pregnant women, patients with advanced complications, a history of repeated severe hypoglycemia, or recurrent DKA (ADA, 2011).
Outcomes
Critical Appraisal Summary
Diet and physical activity ...
Similar to Documentation Clinical Notes - Copy (2) (20)
2. The goals aligned with the patients plan of care
are based on the patient centered functional
goals.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 2
3. Long Term Goal:
The clinical goals are expected to be achievable and
realistic within the designated time frame and the
treatments listed (referred to as the treatment plan)
are necessary to achieve these goals within the
designated time frame.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 3
4. The functional goals were created based on the
reported patient’s prior level of function as
compared to the assessed current level of
function.
Goals are Identified by:
Valid and Reliable functional test
Objective measures
Co-morbidities
Therapist judgment
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 4
5. Test is measuring what it is intended to
measure
Balance
Dizziness
Back Pain
Neck Pain
Leg function
Arm function
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 5
6. Broadly defined:
One is able to rely on the test scores being accurate
and reproducible
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 6
7. Data that are measureable
Impairments
Strength
Pain
Range of Motion
Reflexes
Circumference measures
Function
Functional Tests
TGUG
Berg
Questionnaires
Oswestry
Neck Disability Index
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 7
8. Issue that affect the outcome of treatment
Age
Past Medical History
Family participation
Cognitive Issues
Access to attend PT
Equipment needs
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 8
9. To determine functional status or level of
disability the following must be considered
Prior Level of Function
Severity of Procedure/Pathology/Disease
Objective Impairment Finding
Functional Test(s) scores and the consideration of the
minimally detectable change and cut offs
Motivation of patient and family
Experience of therapist
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 9
11. Outcomes Assessment
Collection and recording of information
relative to health processes
Outcomes Management
Using information in a way that
enhances patient care
(Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical
Application of Outcomes Assessment, Stamford Connecticut,
Appleton & Lange, 2000)
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 11
12. Outcomes in clinical practice provide the
mechanism by which the health care provider,
the patient, the public, and the payer are able to
assess the end results of care and its effect upon
the health of the patient and society.
(Anderson & Weinstein, 1994).
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 12
13. To survive, in fact to flourish, in this era of
accountability health care providers must be
prepared to maintain and be able to provide
appropriate documentation and patient records
in a clinically efficient and economical manner.
(Hansen, 1994).
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 13
14. With the dawning, of the “era of
accountability,” there are new social mandates
directed toward health care providers and
health-related facilities. Measurements of
quality, satisfaction, efficacy, and effectiveness
now serve as essential elements for health care
decisions and matters of health policy.
(Hansen DT, Mior S, Mootz RD in Yeomans SG: The
Clinical Application of Outcomes Assessment,
Stamford Connecticut, Appleton & Lange, 2000)
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 14
15. Health Care Customer - Meaning of Outcomes
Payers-purchasers Cost containment
Regulators HCP compliance
Administrators Efficiency-low utilization
Clinical Researchers Proof of a premise
Outcomes Experts Patient’s benefit
Health Care Providers Clinical-Health Status
(Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical
Application of Outcomes Assessment, Stamford Connecticut,
Appleton & Lange, 2000)
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 15
16. Utility Is it useful?
Reliability Is it dependable?
Validity Does it do what it is supposed to?
Sensitivity Can it identify patients with a
condition?
Specificity Can it identify those that do not
have the condition?
Responsiveness Can it measure differences
over time?
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 16
17. Questionnaires
General health status
Pain
Functional status
Patient satisfaction
Physiological outcomes
Utilization measures
Cost measures
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 17
18. When outcome measures are appropriately
used and integrated into an evidence-based,
patient-centered model of practice, there is
accountability and quality assurance.
(Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical
Application of Outcomes Assessment, Stamford Connecticut,
Appleton & Lange, 2000)
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 18
19. Subjective outcomes assessment information is
gathered by the patient in self-administered
questionnaires and scored by either the:
health care provider
staff members or
by a computer.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 19
20. In spite of the definition associated with the
term “subjective,” these “pen-and-paper tools”
have been described as very valid and reliable
– in many cases more so than many of the
“objective’ tests that health care providers have
relied upon for years.
(Chapman-Smith, 1992; Hansen, 1994; Mootz, 1994).
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 20
21. It must be emphasized that although the term
“subjective” carries negative connotations,
the reliability/validity data published
regarding these methods of collecting
outcomes is exceptional, typically out-
performing the test-retest reliability and
validity of most “objective” physical
performance tests.
(Chapman-Smith, 1992).
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 21
22. Subjective
(Patient Driven)
General Health
Pain Perception
Condition or Disease
Specific
Psychometric
Disability Prediction
Patient Satisfaction
Prior Level of
function
Objective
(HCP Driven)
Range of Motion
Strength - Endurance
Nonorganic
Proprioception
Cardiopulmonary
Developmental
Neurological
Pain (VAS)
Integumentary
Special Test
Functional Tests
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 22
23. It is important to remember to
utilize the same outcome
assessment tool through the
course of case management
with each patient.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 23
24. Progress Note
Re-assessment
Re-evaluation
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 24
25. The progress notes allows the therapist to
determine the effectiveness of the allocated
plan of care and to measure the clinical
findings that are compared to the clinical goals
that establish indicators of progress toward
addressing functional limitations and
achieving functional goals.
Falls hand and hand with the Re-assessment
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 25
26. A re-evaluation is performed when a
significant changes has taken place and there
is an alteration in the plan of care.
Be careful not to over-utilize this code in your
billing methodology
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 26
27. The functional goals are based upon a
correlation of functional assessment tools,
clinical findings/tests, performance based
tests, objective findings and the therapist
judgment call.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 27
28. Impairment:
Loss or abnormality of anatomical, physiological, mental, or
psychological structure or function. Organ specific
Functional Limitation
Restriction of ability to perform, at the level of the whole
person, a physical action, task or activity in an efficient,
typically expected, or competent manner. Person specific.
Disability:
The inability to perform or a limitation in the performance of
actions, tasks, and activities usually expected in specific social
roles.
(Nagi, S. Some conceptual issues in disability and rehabilitation. In : Sussman M, ed Sociology and
Rehabilitation. Washington DC: American Sociology Society; 1965: 100-113)
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 28
29. APTA has numerous publication that address
components of clinical documentation. Below are a list
of three publications that will be discussed.
Guide to Physical Therapy Practice
Peer Review/Utilization Review
Task Force on Measurements
APTA Standards of Tests and Measurements
Primer on Measurement: An introductory guide to
measurement issues. (Rothstein, Echternach)
WHO: International classification of functioning, disability and
health
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 29
31. Dr. Charles Curtis MS, PT,DPT, MDT31
Validity and Reliability. Concurrent
and Retrospective Reviews
5/13/2015
32. Provide services to patients/clients who have
impairments, functional limitation, disabilities
or changes in physical function and health
status resulting from injury, disease or other
causes.
(Guide to Physical Therapy Practice 2nd Edition. pg S31)
Dr. Charles Curtis MS, PT,DPT, MDT 325/13/2015
33. What is needed for Review
The inclusion of the patient in establishing goals:
Patient centered functional goals
A statement of impairment related to functional
limitation
Valid Function Tests with reliable scores
A statement on any changes in health status, wellness,
and fitness needs to be identified
Objective noted with impairment measures
Medicare signed plan of care
Physician signature
MD script for most commercial products
Direct access does not require us to have a script just
communication with patient’s physician
Dr. Charles Curtis MS, PT,DPT, MDT 335/13/2015
34. To set criteria for the effectiveness and
efficiency of a test Peer Review articles are
defined:
Peer-review scientific studies published in, or in
accepted for publication by, medical journals that
meet nationally recognized requirements for
scientific manuscripts and that submit most of their
published articles for review by experts who are not
part of the editorial staff.
Dr. Charles Curtis MS, PT,DPT, MDT 345/13/2015
35. Scope of practice is a key component to keep in mind
as to what services a PT should provide.
Valid and Reliable Measure are an essential part of
clinical documentation.
Scientific literature is the source of information
regarding the application of tests and how to interpret
the findings
Validity: is the test measuring what it claims to
Reliability: is the test consistent and stable and
reproducible.
Dr. Charles Curtis MS, PT,DPT, MDT 355/13/2015
36. Dr. Charles Curtis MS, PT,DPT, MDT36
View on Documentation and Function
5/13/2015
37. Utilization Review Process Defined
The review to determine whether health care
services that have been provided, are being
provided or are proposed to be provided to a
patient, whether undertaken prior to, concurrent
with or subsequent to the delivery of such services
are medically necessary.
Dr. Charles Curtis MS, PT,DPT, MDT 375/13/2015
38. Concurrent Review Defined:
The review preformed at the time of treatment.
Review is performed to determine medical necessity
of the treatment performed and it effect on the
consequence of disease , including
impairments,
functional limitations,
patient centered functional goals that justify treatment,
which lead to the foundation of
medically necessary.
Dr. Charles Curtis MS, PT,DPT, MDT 385/13/2015
39. The fact that a provider and or physician (par
or non par) has made a prescribed,
recommended, or approved a service, supply
or equipment, does not in itself, makes it
medically necessary.
What is required:
Justification through written documentation
utilizing measurement that are valid and reliable
These are the items that are required by a majority
of Utilization review process
Dr. Charles Curtis MS, PT,DPT, MDT 395/13/2015
40. What is required by parties interested in
documentation?
Proof that care is necessary, effective and important
to the patient.
How do we do this?
At the core of proper documentation is the validity and
reliability of the measurements. Linking these
measurement changes, from an impairments view and
the direct association to the functional limitation, of the
patient.
Dr. Charles Curtis MS, PT,DPT, MDT 405/13/2015
42. According to Peat and Campbell (1979)
“…the profession (physical therapy) has been
criticized for not objectively recording events”
Why:
Primary tools in the assessment of motor performance
are visual tools and gross motor test.
Visual test disadvantage is the absence of
quantification of specific parameters of the event
The validity of the test is placed on the therapist
personal observation a particular response.
Dr. Charles Curtis MS, PT,DPT, MDT 425/13/2015
43. To improve our clinical documentation there
must be:
An emphasis on function we must be able to analysis
performance
An analysis of performance is the quantification of
stipulated parameters,
comparison of parameters with respect to a normative
data,
comparison of the present and previous states of results
for the same set of parameters.
Dr. Charles Curtis MS, PT,DPT, MDT 435/13/2015
44. In the analysis of motor performance look to
two components:
Product or outcome
Effectiveness
Efficiency
Process
Biomechanical efficiency
Biomechanics is the science of accelerations, forces, and
displacements acting on the human body and the
injuries caused by these forces
Dr. Charles Curtis MS, PT,DPT, MDT 445/13/2015
45. Effectiveness:
The degree of success attained in the achievement of
the goal
Efficiency:
Ratio of mechanical work accomplished by the total
work accomplished (How much effort to how much
work). Directly related to time, distance, force and
accuracy.
Dr. Charles Curtis MS, PT,DPT, MDT 455/13/2015
46. Biomechanical efficiency
Skill of task.
Exhibited by patient when attempting to perform a
movement
Gross measurement (ie. Gross gait pattern)
Dr. Charles Curtis MS, PT,DPT, MDT 465/13/2015
47. The human body is subject to gravitational
force and through the study of these force we
can maintain or improve a humans overall
quality of life.
Any injury to, or lesion in, any of the
individual elements of the musculoskeletal
system will change the mechanical interaction
and cause degradation, instability or disability
of movement.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 47
48. In response to these negative adaptations:
proper modification, manipulation and control of
the mechanical environment can help prevent injury,
correct abnormality, and speed healing and
rehabilitation.
To Accomplish this,
an understanding the biomechanics and loading of
each element during movement using visual
assessment and or motion analysis is helpful for
studying disease etiology, making decisions about
treatment, and evaluating treatment effects
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 48
49. Proper documentation should follow the same
outline as analysis of movement:
Effectiveness of a functional task should be
measured by the degree of success attained by the
achievement of the task or activity
Efficiency of a functional task to measure time,
distance, force or energy required and accuracy of
the task. (RPE example of measuring this)
Dr. Charles Curtis MS, PT,DPT, MDT 495/13/2015
50. All areas including, research, health care policy
reimbursement practices and the standards of
accrediting bodies all support writing patient-
centered functional goals.
Reason:
It promotes a patient-centered approach in which PT
actively facilitate the participation of the
patient/client, family, significant other and
caregivers in the plan of care.
Dr. Charles Curtis MS, PT,DPT, MDT 505/13/2015
51. Rational for such goals:
Functional Goals are necessary to address the fact
that correction of impairment alone is not directly
functional and may not necessarily lead to
functional improvements or may not be meaningful
to the patient.
Dr. Charles Curtis MS, PT,DPT, MDT 515/13/2015
52. Function: those activities identified by
individual as essential to support physical,
social, and psychological well being and to
create a personal sense of meaningful living.
Goals: remediation of impairment and uses the
term “outcomes” for minimization of
functional limitation, optimization of health
status, prevention of disabilities, and
optimization of patient/client satisfaction.
Primary goal is to maintain and improve the
quality of life of an individual—
empowering independency
Dr. Charles Curtis MS, PT,DPT, MDT 525/13/2015
53. Defined: as the individually meaningful
activities that a person cannot perform as a
result of an injury, illness or congenital or
acquired condition, but want to be able to
accomplish as a result of physical limitation.
Dr. Charles Curtis MS, PT,DPT, MDT 535/13/2015
54. The shift in federal guidelines of cost
reimbursement have alternatively benefited,
bewildered and penalized the clinics.
The potential shift to a dependency of
reimbursement on the evidence based practice
will be required to utilize and document
credible measures of outcomes.
Why? to safe guard our patients interest and to
promote our own professional self interest
Dr. Charles Curtis MS, PT,DPT, MDT 545/13/2015
55. Appropriate question to identify patient
centered functional goals.
Determine the patients desired outcomes
Rank outcomes in priority order. (Ask patient which
of their goals is the most important)
Develop an understanding of patients self care,
work, and leisure activities and environment in
which these activities occur (Life style, hobbies,
activity levels, etc.)
Establish goals with the patient and if necessary
with family that relate to desired outcomes.
Dr. Charles Curtis MS, PT,DPT, MDT 555/13/2015
56. Hypothesis Orientated Algorithm for
Clinicians II (HOAC II)
A new decision making and documentation guide in
physical therapy.
It is to serve as a template for documentation and as
a conceptual model for decision making and
therefore, could link documentation and practice.
Dr. Charles Curtis MS, PT,DPT, MDT 565/13/2015
57. Algorithm presented provide a problem
solving approach to clinical decision
Divides patient problems into two categories
Patient identified problems (PIP):
Non patient identified problems
(NPIP):
Dr. Charles Curtis MS, PT,DPT, MDT 575/13/2015
58. Consist of functional limitations and
disabilities identified by patient, will
often exist when therapist is performing
initial evaluation, however these items
can also be anticipated by the therapist.
Generated before examination, therefore
driven by patient.
Dr. Charles Curtis MS, PT,DPT, MDT 585/13/2015
59. Problems that may occur (Risk Factors)
or existing problems not expressed by
the patient, but found by therapist.
Dr. Charles Curtis MS, PT,DPT, MDT 595/13/2015
60. Testing Criteria
Used to examine correctness of hypothesis related to problems
that currently exist. Informs us of the level of performance that
a patient needs to achieve to eliminate a problem (impairment
and functional limitation).
Predictive Criteria
Measured for anticipated problems. How long intervention for
prevention should be carried out. A focus on risk factors that
lead to corrective hypothesis, reduced risk factors. These are
not goals because they are worth achieving only if sufficient
evidence indicates that a problems might occur.
Dr. Charles Curtis MS, PT,DPT, MDT 605/13/2015
61. HOAC II:
prevention activities are goal driven and are planned
for specified period of time, therapists can, through
use of the algorithm, identify to payers the resources
they will need to achieve prevention.
Dr. Charles Curtis MS, PT,DPT, MDT 615/13/2015
62. With two types of problems two types of
hypotheses are needed (Evidence-Based
Preferred or Logic as to the need)
Existing Problems Hypotheses: requires hypotheses
about the diagnosis that detail what needs to be
changed to eliminate existing problems.
Anticipated Problems: Elimination of risk factors
and a case as to what may happen with out
intervention.
Dr. Charles Curtis MS, PT,DPT, MDT 625/13/2015
63. Rational for the intervention to avoid a
problem is difficult. Must look to the risk
factors and the removal of such.
Epidemiological base
Augmentative / Logic base with some type of
scientific basis
Justification is critical with this type of problem.
Dr. Charles Curtis MS, PT,DPT, MDT 635/13/2015
64. Goals: To base a goal on the change in
impairment is almost always inappropriate
Goals should represent meaningful
accomplishments. Changes are functional
Dr. Charles Curtis MS, PT,DPT, MDT 645/13/2015
65. The simplest way of checking whether a goal is
appropriate
Whether the payer would find therapy to be
worthwhile if this is all that is achieved
Whether anyone would feel therapy was worthwhile
if this is all that was achieved
Commit to a evaluation schedule, identifiable
time lines when status of patient will be
checked
Dr. Charles Curtis MS, PT,DPT, MDT 655/13/2015
66. Dr. Charles Curtis MS, PT,DPT, MDT 66
Provide measurement tools to clinical
personnel and qualify existing
documents, training and competency
Make all clinical personnel accountable
to documentation requirements
Quality assurance preformed on
documentation (Peer Review ¼’ly) with
reports and action plans. Included in
yearly review
5/13/2015
67. Improve the field of physical therapy
Improve the quality of care to patients
Improve efficiency and effectiveness of care
with closer monitoring
Reduce denials for utilization review
Add to evidence based practice data base with
published outcomes
Provide data to potential clients
Dr. Charles Curtis MS, PT,DPT, MDT 675/13/2015
68. Points to Remember
Document all objective data on evaluation
Compare prior level of function to current level
Medicare looks at a 90-180 day as the time line.
Link all functional limitations with impairments
Re-measure often to determine effectiveness
Use measurements that are valid and reliable
All goals should be patient centered, realistic and functional.
Good documentation leads to justification of treatments that
leads to improved quality of care to patients
Dr. Charles Curtis MS, PT,DPT, MDT 685/13/2015
69. 1) Six minute walk test (pulmonary/cardiac)
Olsson L, Swedberg K. Eur Heart J. 2005 Oct;26(20):2209. Epub 2005 Aug 16.
2) DASH (upper extremity)
Deshmukh, AV et al. Total shoulder arthroplasty: Long-term survivorship, functional outcome,
and quality of life. J Shoulder Elbow Surg. 2005 Sep-Oct;14(5):471-9.
3) Oswastry (low back)
Ostelo, RW, de Vet HC. Clinically important outcomes in low back pain.
Best Pract Res Clin Rheumatol. 2005 Aug;19(4):593-607. Review
4) Neck index
Wlodyka-Demaillle, S.The ability to change of three questionnaires for neck pain.
Joint Bone Spine. 2004 Jul;71(4):317-26.
5) Lower Extremity Motor Coordination Test
Desrosiers, J. et al. Validation of a new lower-extremity motor coordination test.
Arch Phys Med Rehabil. 2005 May;86(5):993-8.
6) Berg balance (out patient)
Paltamaa, J. et al Reliability of physical functioning measures in ambulatory subjects with MS.
Physiother Res Int. 2005;10(2):93-109.
PMID: 15895347
7) Tinnitte (snf, long term care)
Mold, JW et al. The prevalence, predictors, and consequences of peripheral sensory neuropathy in older
patients.
J Am Board Fam Pract. 2004 Sep-Oct;17(5):309-18.
Dr. Charles Curtis MS, PT,DPT, MDT 695/13/2015
71. The ICD-9 and CPT code match up
CCI edits with CPT codes
Documentation:
Functional
Objective Test
Valid
Reliable
Dr. Charles Curtis MS, PT,DPT, MDT 715/13/2015
72. Dr. Charles Curtis MS, PT,DPT, MDT72
ICD-9 CPT code
Match-up
Medical
Necessity
CCI Edits
Functional Changes via
Documentation of patients
Centered Functional Goals
5/13/2015
73. Documentation required to indicate objective, measurable
beneficiary physical function including, e.g.,
Functional assessment individual item and summary
scores (and comparisons to prior assessment scores)
from commercially available therapy outcomes
instruments other than those listed above; or
Functional assessment scores (and comparisons to
prior assessment scores) from tests and measurements
validated in the professional literature that are
appropriate for the condition/function being
measured; or
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 73
74. Other measurable progress towards identified
goals for functioning in the home environment
at the conclusion of this therapy episode of
care.
Clinician’s clinical judgments or subjective
impressions that describe the current functional
status of the condition being evaluated, when
they provide further information to
supplement measurement tools; and
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 74
75. A determination that treatment is not needed, or, if
treatment is needed a prognosis for return to
premorbid condition or maximum expected condition
with expected time frame and a plan of care.
Clinician’s clinical judgments or subjective impressions
that describe the current functional status of the
condition being evaluated, when they provide further
information to supplement measurement tools; and
A determination that treatment is not needed, or, if
treatment is needed a prognosis for return to
premorbid condition or maximum expected condition
with expected time frame and a plan of care.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 75
76. Documentation supporting medical care prior to
the current episode, if any, (or document none)
including, e.g.,
Record of discharge from a Part A qualifying inpatient,
SNF, or home health episode within 30 days of the onset
of this outpatient therapy episode, or
Identification of whether beneficiary was treated for this
same condition previously by the same therapy discipline
(regardless of where prior services were furnished; and
Record of a previous episode of therapy treatment from
the same or different therapy discipline in the past year.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 76
77. Documentation required to indicate beneficiary
health related to quality of life, specifically,
The beneficiary’s response to the following question
of self-related health: “At the present time, would
you say that your health is excellent, very good, fair,
or poor?” If the beneficiary is unable to respond,
indicate why; and
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 77
78. Documentation required to indicate
beneficiary social support including,
specifically,
Where does the beneficiary live (or intend to live) at the
conclusion of this outpatient therapy episode? (e.g.,
private home, private apartment, rented room, group
home, board and care apartment, assisted living, SNF),
and
Who does beneficiary live with (or intend to live with) at
the conclusion of this outpatient therapy episode? (e.g.,
lives alone, spouse/significant other, child/children,
other relative, unrelated person(s), personal care
attendant), and
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 78
79. Does the beneficiary require this outpatient therapy
plan of care in order to return to a premorbid (or
reside in a new) living environment, and
Does the beneficiary require this outpatient therapy
plan of care in order to reduce Activities of Daily
Living (ADL) or Instrumental Activities of Daily
Living or (IADL) assistance to a premorbid level or
to reside in a new level of living environment
(document prior level of independence and current
assistance needs); and
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 79
80. Progress Note:
Timing. The minimum Progress Report Period shall be at least
once every 10 treatment days or at least once during each 30
calendar days, whichever is less.
The day beginning the first reporting period is the first day of the
episode of treatment regardless of whether the service provided
on that day is an evaluation, re-evaluation or treatment.
Regardless of the date on which the report is actually written (and
dated),
the end of the Progress Report Period is either a date chosen by
the clinician, the 10th treatment day, or the 30th calendar day of the
episode of treatment, whichever is shorter.
The next treatment day begins the next reporting period. The
Progress Report Period requirements are complete when both the
elements of the Progress Report and the clinician’s active
participation in treatment have been documented.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 80
81. The Discharge Note or Discharge Summary:
is required for each episode of outpatient treatment. In
provider settings where the physician/NPP writes a
discharge summary and the discharge documentation meets
the requirements of the provider setting, a separate
discharge note written by a therapist is not required.
The Discharge Note shall be a Progress Report written by a
clinician, and shall cover the reporting period from the last
Progress Report to the date of discharge.
In the case of a discharge unanticipated in the plan or
previous Progress Report, the clinician may base any
judgments required to write the report on the Treatment
Notes and verbal reports of the assistant or qualified
personnel.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 81
82. At the discretion of the clinician, the discharge
note may include additional information; for
example, it may summarize the entire episode of
treatment, or justify services that may have
extended beyond those usually expected for the
patient’s condition.
Clinicians should consider the discharge note
the last opportunity to justify the medical
necessity of the entire treatment episode in case
the record is reviewed. The record should be
reviewed and organized so that the required
documentation is ready for presentation to the
contractor if requested.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 82
83. The purpose of these notes is simply to create a
record of all treatments and skilled interventions
and to record the time of the services in order to
justify the use of billing codes on the claim.
Documentation is required for every treatment
day, and every therapy service.
The Treatment Note is not required to document
the medical necessity or appropriateness of the
ongoing therapy services.
Descriptions of skilled interventions should be
included in the plan or the Progress Reports and
are allowed, but not required daily.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 83
84. Non-skilled interventions need not be recorded
in the Treatment Notes as they are not billable.
However, notation of non-skilled treatment or
report of activities performed by the patient or
non-skilled staff may be reported voluntarily as
additional information if they are relevant and
not billed.
Specifics such as number of repetitions of an
exercise and other details included in the plan
of care need not be repeated in the Treatment
Notes unless they are changed from the plan.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 84
85. Documentation of each Treatment
shall include the following required
elements:
Date of treatment; and
Identification of each specific intervention/modality
provided and billed, for both timed and untimed
codes, in language that can be compared with the
billing on the claim to verify correct coding. Record
each service provided that is represented by a timed
code, regardless of whether or not it is billed,
because the unbilled timed services may impact the
billing; and
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 85
86. Total timed code treatment minutes and total
treatment time in minutes. Total treatment time
includes the minutes for timed code treatment and
untimed code treatment.
Total treatment time does not include time for
services that are not billable (e.g., rest periods). For
Medicare purposes, it is not required that unbilled
services that are not part of the total treatment
minutes be recorded, although they may be included
voluntarily to provide an accurate description of the
treatment, show consistency with the plan, or
comply with state or local policies.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 86
87. The amount of time for each specific
intervention/modality provided to the patient may
also be recorded voluntarily, but contractors shall
not require it, as it is indicated in the billing.
The billing and the total timed code treatment
minutes must be consistent. See Pub. 100-04, chapter
5, section 20.2 for description of billing timed codes;
and
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 87
88. Signature and professional identification of the
qualified professional who furnished or
supervised the services and a list of each person
who contributed to that treatment (i.e., the
signature of Kathleen Smith, PTA, with notation of
phone consultation with Judy Jones, PT,
supervisor, when permitted by state and local
law).
The signature and identification of the supervisor
need not be on each Treatment Note, unless the
supervisor actively participated in the treatment.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 88
89. Since a clinician must be identified on the Plan of Care
and the Progress Report, the name and professional
identification of the supervisor responsible for the
treatment is assumed to be the clinician who wrote the
plan or report. When the treatment is supervised
without active participation by the supervisor, the
supervisor is not required to cosign the Treatment
Note written by a qualified professional.
When the responsible supervisor is absent, the
presence of a similarly qualified supervisor on the
clinic roster for that day is sufficient documentation
and it is not required that the substitute supervisor
sign or be identified in the documentation.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 89
90. If a treatment is added or changed under the
direction of a clinician during the treatment days
between the Progress Reports, the change must be
recorded and justified on the medical record, either
in the Treatment Note or the Progress Report, as
determined by the policies of the
provider/supplier.
New exercises added or changes made to the
exercise program help justify that the services are
skilled. For example: The original plan was for
therapeutic activities, gait training and
neuromuscular re-education. “On Feb. 1 clinician
added electrical stim. to address shoulder pain.”
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 90
91. Documentation of each treatment may also include
the following optional elements to be mentioned
only if the qualified professional recording the
note determines they are appropriate and relevant.
If these are not recorded daily, any relevant
information should be included in the progress
report.
Patient self-report;
Adverse reaction to intervention;
Communication/consultation with other
providers(e.g., supervising clinician, attending
physician, nurse, another therapist, etc.);
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 91
92. Significant, unusual or unexpected changes in clinical status;
services that are not part of the total treatment minutes
be recorded, although they may be included
voluntarily to provide an accurate description of the
treatment, show consistency with the plan, or comply
with state or local policies. The amount of time for each
specific intervention/modality provided to the patient
may also be recorded voluntarily, but contractors shall
not require it, as it is indicated in the billing. The
billing and the total timed code treatment minutes
must be consistent. See Pub. 100-04, chapter 5, section
20.2 for description of billing timed codes
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 92
94. Under certain circumstances, the physician
may need to indicate that a procedure or
service was distinct or independent from other
services performed on the same day. Modifier
59 is used to identify procedures/services that
are not normally reported together, but are
appropriate under the circumstances.
Dr. Charles Curtis MS, PT,DPT, MDT 945/13/2015
95. NCCI edits define when two procedure
HCPCS/CPT codes may not be reported
together except under special circumstances.
For the NCCI its primary purpose is to indicate
that two or more procedures are performed at
different anatomic sites or different patient
encounters.
Dr. Charles Curtis MS, PT,DPT, MDT 955/13/2015
96. Example: Column 1 Code/Column 2 Code 97140/97530
CPT Code 97140 – Manual therapy techniques (eg,
mobilization/manipulation, manual lymphatic drainage,
manual traction), one or more regions, each 15 minutes
CPT Code 97530 – Therapeutic activities, direct (one-on-one)
patient
contact by the provider (use of dynamic activities to improve
functional performance), each 15 minutes
Policy: Mutually exclusive procedures
Modifier -59 is:
Only appropriate if the two procedures are performed in
distinctly
different 15 minute intervals.
The two codes cannot be reported together if performed
during the
same 15 minute time interval.
Dr. Charles Curtis MS, PT,DPT, MDT 965/13/2015
97. Use the KX modifier only in cases where the
condition of the individual patient is such that
services are APPROPRIATELY provided in an
episode that exceeds the cap.
Routine use of the KX modifier for all patients
with these conditions will likely show up on
data analysis as aberrant and invite inquiry. Be
sure that documentation is sufficiently detailed
to support the use of the modifier.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 97
98. COMPLEXITIES are complicating factors that
may influence treatment, e.g., they may
influence the type, frequency, intensity and/or
duration of treatment.
Complexities may be represented by diagnoses
(ICD-9 codes), by patient factors such as age,
severity, acuity, multiple conditions, and
motivation, or by the patient’s social
circumstances such as the support of a
significant other or the availability of
transportation to therapy.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 98
99. Documentation supporting illness severity or
complexity including, e.g.,
Identification of other health services concurrently
being provided for this condition (e.g., physician,
PT, OT, SLP, chiropractic, nurse, respiratory
therapy, social services, psychology,
nutritional/dietetic services, radiation therapy,
chemotherapy, etc.), and/ or
Identification of durable medical equipment
needed for this condition, and/or
Identification of the number of medications the
beneficiary is talking (and type if known); and/or
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 99
100. If complicating factors (complexities) affect treatment, describe
why or how. For example: Cardiac dysrhythmia is not a
condition for which a therapist would directly treat a patient,
but in some patients such dysrhythmias may so directly and
significantly affect the pace of progress in treatment for other
conditions as to require an exception to caps for necessary
services. Documentation should indicate how the progress was
affected by the complexity. Or, the severity of the patient’s
condition as reported on a functional measurement tool may be
so great as to suggest extended treatment is anticipated; and/or
Generalized or multiple conditions. The beneficiary has, in
addition to the primary condition being treated, another disease
or condition being treated, or generalized musculoskeletal
conditions, or conditions affecting multiple sites and these
conditions will directly and significantly impact the rate of
recovery; and/or.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 100
101. Mental or cognitive disorder. The beneficiary has a
mental or cognitive disorder in addition to the
condition being treated that will directly and
significantly impact the rate of recovery; and/or.
Identification of factors that impact severity
including e.g., age, time since onset, cause of the
condition, stability of symptoms, how
typical/atypical are the symptoms of the diagnosed
condition, availability of an intervention/treatment
known to be effective, predictability of progress.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 101
102. Mental or cognitive disorder. The beneficiary has a
mental or cognitive disorder in addition to the
condition being treated that will directly and
significantly impact the rate of recovery; and/or.
Identification of factors that impact severity
including e.g., age, time since onset, cause of the
condition, stability of symptoms, how
typical/atypical are the symptoms of the diagnosed
condition, availability of an intervention/treatment
known to be effective, predictability of progress.
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 102
103. 1) Nagi, S. Disability concepts revisited: implication for prevention. In: Pope AM, Tarlov AR, eds.
Disability in America: Toward a National Agenda for Prevention. Washington, DC: National
Academy Press, 1991.
2) Guide to Physical Therapy Practice. 2nd ed. Physical Therapy. 2001;81:9-744.
3) Jette AM. Physical disablement concepts for physical therapy research and practice. Phys Ther.
1994;74:380-386.
4) Ware JE Jr, Sherbourne CD. The MOS 36-item short form health survey (SF-36), I: conceptual
framework and item selection. Med Care. 1992:30:473-483.
5) Roland M, Morris R. A study of the natural history of back pain, part 1: development of a
reliable and sensitive measure of disability in low back pain. Spine. 1983;8:141-144.
6) Stratford PW, Binkley JM, Solomon P, et al. Defining the minimum level of detectable change
for the Roland-Morris questionnaire. Phys Ther. 1996;76:365.
7) International Classification of Impairments Disabilities and Handicaps. Geneva, Switzerland,
World Health Organization, 1980.
8) Moorhead, JF, Clifford, J. Determining Medical Necessity of Outpatient Services. American
College of Medical Quality. 1992;7(3);81-4.
9) Cyriax, J. The advantage of accurate treatment. Physiotherapy. 1952 Jan;38(1):3-8
10) Zitsmann, SL. Utilization Management of Worker’s Compensation: Out patient Therapy.
JHQ:1993;15(3):34-7.
11) http://www.rehabmeasures.org/default.aspx
Dr. Charles Curtis MS, PT,DPT, MDT 1035/13/2015
104. Contact Information
Dr. Charles Curtis MS, PT, DPT, MDT
33 Orchard Place Little Silver, NJ 07739
732-320-0768
ccurtis33@verizon.net
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 104