Long Term Goals (LTGs) state the final product to be achieved by physical therapy intervention. Expected functional outcomes are a type of LTG
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2 Long Term Goals (LTGs) state the final product to be achieved by physical therapy intervention. Expected functional outcomes are a type of LTG
3 help in planning the treatment to meet specific needs and functional limitations identified during the evaluation of the patient
4 assist in the prioritization of treatment to communicate the expected result for the therapeutic outcome
5 audience (who will exhibit the skill) behavior (what will the audience do) condition (under what circumstances will the audience perform the behavior) degree (how well will the behavior be done)
6 Goals must be written to include the action (performance) of a specific task or function (e.g. ambulation), a measurable criteria that determines the accomplishment of a task (e.g. from bedroom the kitchen), and a time frame during which the goal will be met (e.g. 1 week).
7 Audience: almost always is the pt., but it might be a family member the pt. will demonstrate ; the pt. s husband will be
8 the audience is NEVER the therapist Behavior: this is always a verb followed by the object of the behavior. Typically this is a functional behavior.
9 The behavior must be something that can be measured or described accurately so as to document achievement of the goal.
10 the pt. will demonstrate head control 100% of the time. the pt. will be independent in amb and transfers to provide the pt. independent mobility within the home. (demonstrate is implied)
11 be and know do not describe observable and measurable activities and are not appropriate terms for documentation since they are not measurable
12 Condition: circumstances under which the behavior must be done or conditions necessary for the behavior to occur pt. will demonstrate independent amb with a walker on level surfaces and curbs for unlimited distances within 3 weeks to allow pt. independent mobility at home
13 Degree: includes the minimal number (e.g. 40 ft), the percentage or proportion (e.g. 3 out of 4), any limitation (e.g. strength to 4/5), or any distinguishing features of successful performance (RLE strength = to that of LLE using Cybex) 40 feet
14 must be realistic, measurable, or observable must name a specific time span in which the goal will be achieved must be expressed in terms of function
15 increase R elbow extension AROM to within 10 degrees of full extension (measurable) within 2 weeks (time frame) to improve pt. s ability to reach into overhead cabinets at home (functional terms)
16 Often, the final functional phrase is omitted. The advantage to adding it is to notify third-party payers of the functional reason for the goal. If it is omitted, and the insurance company needs further explanation, a representative will call and speak with the therapist to clarify the functional portion of the goal.
17 LTGs may require revision if: pt. s condition changes and will not allow progression to the functional level set pt. s condition changes and allows progression beyond that level originally set time span is no longer appropriate and need to be revised
18 Once the problems are identified, a LTG is set to address each problem. It is acceptable for one goal to address more than one problem. In New Jersey, goal setting is not just a good idea, it s the law!
19 (a) A licensed physical therapist shall prepare and maintain for each patient a contemporaneous, permanent patient record that accurately reflects the patient contact with the licensed physical therapist whether in an office, hospital or other treatment, evaluation or consultation setting.
20 (b) A licensed physical therapist shall not falsify a patient's record. (c) The patient record shall include, in addition to personal identifying information, consents and disclosures, at least the following information:
21 I. The full name, as it appears on the license, of the licensee who rendered care, identification of licensure status (PT or PTA), and license number. This information shall be legible and shall appear at least once on each page of the patient record; 2. Dates of all examinations, evaluations, physical therapy diagnoses, prognoses including the established plans of care, and interventions;
22 3. The findings of the examination including test results; 4. The conclusion of the evaluation; 5. The determination of the physical therapy diagnosis and prognosis; 6. Documentation of health care practitioner referrals, if any;
23 7. A plan of care establishing measurable goals of the intervention with stated time frames, the type of intervention and the frequency and expected duration of intervention; 8. A contemporaneous note that accurately represents the services rendered during the treatment sessions including, but not limited to, the components of intervention, the patient's response to intervention and current status;
24 9. Progress notes in accordance with stated goals at a frequency consistent with physical therapy diagnosis, evaluative findings, prognosis and changes in the patient's conditions; 10. The signature or initials and license number of the licensee who rendered care. If the licensee chooses to sign by means of initials, his or her complete signature and license number shall appear at least once on every page;
25 II. Changes in the plan of care which shall be documented contemporaneously; 12. Communication with other health professionals relative to the patient's care; 13. A discharge summary which includes the reason for discharge from and outcome of physical therapy intervention relative to established goals at the time of discharge; and
26 14. Pertinent legal document(s). (d) When a licensed physical therapist provides training in techniques for the prevention of injury, impairment, movement- related functional limitation or dysfunction that is not specifically designed for an individual, the licensed physical therapist shall not be required to maintain records that comply with (c) above. A licensed physical therapist that provides such training shall maintain records that include:
27 I. The name and license number of the licensed physical therapist who provided the training; 2. The date the training was provided; 3. A summarization of the information that was provided; and 4. Copies of any handouts provided. (e) Patient records shall be maintained for at least seven years from the date of the last entry, unless another agency or entity requires the records to be kept for a longer time.
28 LTGs are listed in order of priorities. Short term goals: are set as steps along the way to achieving the LTGs. If the pt. will not be seen long enough to require both LTGs and Short Term Goals (STGs), the STGs are omitted.
29 type of LTG expressed purely in terms of function with no mention of increases in ROM and strength. It is assumed that the limitations in ROM, strength, etc. will be addressed to the extent necessary to achieve the functional outcome.
30 reasons for writing them, structure, revision, and priorities are the same as those for LTG Audience, Behavior, Condition Functional outcomes! Measurable goals! Behavioral terminology! Patient focused!
31 when STGs are set, the course of treatment is determined. When a treatment plan is set up, treatment interventions to work toward each of the STGs must be included.
32 if the STG is met, a new one is established if a STG is not met, the therapist comments on the reason why it has not been achieved and resets the goal
33 PTAs do not design the treatment goals or functional outcomes, but PTAs can work with the PT in offering suggestions, notifying the PT when goals are met, and recognizing when the PT needs to modify or change goals
34 Remember that you are the PT s eyes, ears and hands! Your input is important and necessary to progress the patient. You can make suggestions to the plan to progress the pt.
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If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment.
Welcome to POST Physical Therapy Brookline. We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health care is something that we at POST Physical
THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:
THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: Social Security Number: Employment Status: Marital Status: Emp Unemp
May 7, 2012. Submitted Electronically
May 7, 2012 Submitted Electronically Secretary Kathleen Sebelius Department of Health and Human Services Office of the National Coordinator for Health Information Technology Attention: 2014 edition EHR
Physical Therapy Sample Reports 2009
Sample Reports 2009 Includes: Progress/ Treatment Note Plan of Care from Initial Evaluation Initial Evaluation/ Examination (full-length compliant) Ten (10) Visit Progress Report Discharge Summary Physician
Medical Record Documentation Standards
Medical Record Documentation Standards Medical Record Documentation Standards and Performance Measures Compliance with the Standards is monitored as part of our Quality Improvement Program. Practitioner
STATE LANGUAGE Code of Alabama 34-24-191. Definitions. Alabama Administrative Code 700-x-3-.03(2) 700-x-3-.03(3)(a) 700-x-3-.
American Physical Therapy Association Government Affairs Department Review of Physical Therapy Practice Acts and Rules on Supervision of PTAs, Aides and Other Assistive Personnel October 2005 STATE AL