GUIDELINES: PHYSICAL THERAPY DOCUMENTATION OF PATIENT/CLIENT MANAGEMENT BOD G

Transcription

1 GUIDELINES: PHYSICAL THERAPY DOCUMENTATION OF PATIENT/CLIENT MANAGEMENT BOD G [Amended BOD ; BOD ; BOD ; BOD ; BOD ; BOD ; BOD ; BOD ; BOD ; BOD ; Initial BOD ] [Guideline] PREAMBLE The American Physical Therapy Assciatin (APTA) is cmmitted t meeting the physical therapy needs f sciety, t meeting the needs and interests f its members, and t develping and imprving the art and science f physical therapy, including practice, educatin and research. T help meet these respnsibilities, APTA s Bard f Directrs has apprved the fllwing guidelines fr physical therapy dcumentatin. It is recgnized that these guidelines d nt reflect all f the unique dcumentatin requirements assciated with the many specialty areas within the physical therapy prfessin. Applicable fr bth hand written and electrnic dcumentatin systems, these guidelines are intended t be used as a fundatin fr the develpment f mre specific dcumentatin guidelines in clinical areas, while at the same time prviding guidance fr the physical therapy prfessin acrss all practice settings. Dcumentatin may als need t address additinal regulatry r payer requirements. Finally, be aware that these guidelines are intended t address dcumentatin f patient/client management, nt t describe the prvisin f physical therapy services. Other APTA dcuments, including APTA Standards f Practice fr Physical Therapy, Cde f Ethics and Guide fr Prfessinal Cnduct, and the Guide t Physical Therapist Practice, address prvisin f physical therapy services and patient/client management. APTA POSITION ON DOCUMENTATION Dcumentatin Authrity Fr Physical Therapy Services Physical therapy examinatin, evaluatin, diagnsis, prgnsis, and plan f care (including interventins) shall be dcumented, dated, and authenticated by the physical therapist wh perfrms the service. Interventins prvided by the physical therapist r selected interventins prvided by the physical therapist assistant under the directin and supervisin f the physical therapist are dcumented, dated, and authenticated by the physical therapist r, when permissible by law, the physical therapist assistant. Other ntatins r flw charts are cnsidered a cmpnent f the dcumented recrd but d nt meet the requirements f dcumentatin in r f themselves. Students in physical therapist r physical therapist assistant prgrams may dcument when the recrd is additinally authenticated by the physical therapist r, when permissible by law, dcumentatin by physical therapist assistant students may be authenticated by a physical therapist assistant. OPERATIONAL DEFINITIONS Guidelines APTA defines a "guideline" as a statement f advice.

2 Authenticatin The prcess used t verify that an entry is cmplete, accurate and final. Indicatins f authenticatin can include riginal written signatures and cmputer "signatures" n secured electrnic recrd systems nly. The fllwing describes the main dcumentatin elements f patient/client management: 1) initial examinatin/evaluatin, 2) visit/encunter, 3) reexaminatin, and 4) discharge r discntinuatin summary. Initial Examinatin/Evaluatin Dcumentatin f the initial encunter is typically called the initial examinatin, initial evaluatin, r initial examinatin/evaluatin. Cmpletin f the initial examinatin/ evaluatin is typically cmpleted in ne visit, but may ccur ver mre than ne visit. Dcumentatin elements fr the initial examinatin/evaluatin include the fllwing: Examinatin: Includes data btained frm the histry, systems review, and tests and measures. Evaluatin: Evaluatin is a thught prcess that may nt include frmal dcumentatin. It may include dcumentatin f the assessment f the data cllected in the examinatin and identificatin f prblems pertinent t patient/client management. Diagnsis: Indicates level f impairment, activity limitatin and participatin restrictin determined by the physical therapist. May be indicated by selecting ne r mre preferred practice patterns frm the Guide t Physical Therapist Practice. Prgnsis: Prvides dcumentatin f the predicted level f imprvement that might be attained thrugh interventin and the amunt f time required t reach that level. Prgnsis is typically nt a separate dcumentatin elements, but the cmpnents are included as part f the plan f care. Plan f care: Typically stated in general terms, includes gals, interventins planned, prpsed frequency and duratin, and discharge plans. Visit/Encunter Dcumentatin f a visit r encunter, ften called a prgress nte r daily nte, dcuments sequential implementatin f the plan f care established by the physical therapist, including changes in patient/client status and variatins and prgressins f specific interventins used. Als may include specific plans fr the next visit r visits. Reexaminatin Dcumentatin f reexaminatin includes data frm repeated r new examinatin elements and is prvided t evaluate prgress and t mdify r redirect interventin. Discharge r Discntinuatin Summary Dcumentatin is required fllwing cnclusin f the current episde in the physical therapy interventin sequence, t summarize prgressin tward gals and discharge plans. GENERAL GUIDELINES Dcumentatin is required fr every visit/encunter. All dcumentatin must cmply with the applicable jurisdictinal/regulatry requirements. All handwritten entries shall be made in ink and will include riginal signatures. Electrnic entries are made with apprpriate security and cnfidentiality prvisins. Charting errrs shuld be crrected by drawing a single line thrugh the errr and initialing and dating the chart r thrugh the apprpriate mechanism fr electrnic

3 dcumentatin that clearly indicates that a change was made withut deletin f the riginal recrd. All dcumentatin must include adequate identificatin f the patient/client and the physical therapist r physical therapist assistant: The patient's/client's full name and identificatin number, if applicable, must be included n all fficial dcuments. All entries must be dated and authenticated with the prvider's full name and apprpriate designatin: Dcumentatin f examinatin, evaluatin, diagnsis, prgnsis, plan f care, and discharge summary must be authenticated by the physical therapist wh prvided the service. Dcumentatin f interventin in visit/encunter ntes must be authenticated by the physical therapist r physical therapist assistant wh prvided the service. Dcumentatin by physical therapist r physical therapist assistant graduates r ther physical therapists and physical therapist assistants pending receipt f an unrestricted license shall be authenticated by a licensed physical therapist, r, when permissible by law, dcumentatin by physical therapist assistant graduates may be authenticated by a physical therapist assistant. Dcumentatin by students (SPT/SPTA) in physical therapist r physical therapist assistant prgrams must be additinally authenticated by the physical therapist r, when permissible by law, dcumentatin by physical therapist assistant students may be authenticated by a physical therapist assistant. Dcumentatin shuld include the referral mechanism by which physical therapy services are initiated. Examples include: Self-referral/direct access Request fr cnsultatin frm anther practitiner Dcumentatin shuld include indicatin f n shws and cancellatins. INITIAL EXAMINATION/EVALUATION Examinatin (Histry, Systems Review, and Tests and Measures) Histry: Dcumentatin f histry may include the fllwing: General demgraphics Scial histry Emplyment/wrk (Jb/Schl/Play) Grwth and develpment Living envirnment General health status (self-reprt, family reprt, caregiver reprt) Scial/health habits (past and current) Family histry Medical/surgical histry Current cnditin(s)/chief cmplaint(s) Functinal status and activity level Medicatins Other clinical tests Systems Review: Dcumentatin f systems review may include gathering data fr the fllwing systems: Cardivascular/pulmnary

4 Bld Pressure Edema Heart Rate Respiratry Rate Integumentary Pliability (texture) Presence f scar frmatin Skin clr Skin integrity Musculskeletal Grss range f mtin Grss strength Grss symmetry Height Weight Neurmuscular Grss crdinated mvement (eg, balance, lcmtin, transfers, and transitins) Mtr functin (mtr cntrl, mtr learning) Dcumentatin f systems review may als address cmmunicatin ability, affect, cgnitin, language, and learning style: Ability t make needs knwn Cnsciusness Expected emtinal/behaviral respnses Learning preferences (eg, educatin needs, learning barriers) Orientatin (persn, place, time) Tests and Measures: Dcumentatin f tests and measures may include findings fr the fllwing categries: Aerbic Capacity/Endurance Aerbic capacity during functinal activities Aerbic capacity during standardized exercise test prtcls Cardivascular signs and symptms in respnse t increased xygen demand with exercise r activity Pulmnary signs and symptms in respnse t increased xygen demand with exercise r activity Anthrpmetric Characteristics Bdy cmpsitin Bdy dimensins Edema Arusal, attentin, and cgnitin Arusal and attentin Cgnitin Cmmunicatin Cnsciusness Mtivatin

5 Orientatin t time, persn, place, and situatin Recall Assistive and adaptive devices Assistive r adaptive devices and equipment use during functinal activities Cmpnents, alignment, fit, and ability t care fr the assistive r adaptive devices and equipment Remediatin f impairments, activity limitatins and participatin restrictins with use f assistive r adaptive devices and equipment Safety during use f assistive r adaptive devices and equipment Circulatin (Arterial, Venus, Lymphatic) Cardivascular signs Cardivascular symptms Physilgical respnses t psitin change Cranial and Peripheral Nerve Integrity Electrphysilgical integrity Mtr distributin f the cranial nerves Mtr distributin f the peripheral nerves Respnse t neural prvcatin Respnse t stimuli, including auditry, gustatry, lfactry, pharyngeal, vestibular, and visual Sensry distributin f the cranial nerves Sensry distributin f the peripheral nerves Envirnmental, Hme, and Wrk (Jb/Schl/Play) Barriers Current and ptential barriers Physical space and envirnment Ergnmics and Bdy mechanics Examples f examinatin findings fr ergnmics include: Dexterity and crdinatin during wrk Functinal capacity and perfrmance during wrk actins, tasks, r activities Safety in wrk envirnments Specific wrk cnditins r activities Tls, devices, equipment, and wrk-statins related t wrk actins, tasks, r activities Examples f examinatin findings fr bdy mechanics include: Bdy mechanics during self-care, hme management, wrk, cmmunity, r leisure actins, tasks, r activities Gait, lcmtin, and balance Balance during functinal activities with r withut the use f assistive, adaptive, rthtic, prtectin, supprtive, r prsthetic devices r equipment

6 Balance (dynamic and static) with r withut the use f assistive, adaptive, rthtic, prtective, supprtive, r prsthetic devices r equipment Gait and lcmtin during functinal activities with r withut the use f assistive, adaptive, rthtic, prtective, supprtive, r prsthetic devices r equipment Gait and lcmtin with r withut the use f assistive, adaptive, rthtic, prtective, supprtive, r prsthetic devices r equipment Safety during gait, lcmtin, and balance Integumentary Integrity Assciated skin: Activities, psitining, and pstures that prduce r relieve trauma t the skin Assistive, adaptive, rthtic, prtective, supprtive, r prsthetic devices and equipment that may prduce r relieve trauma t the skin Skin characteristics Wund Activities, psitining, and pstures that aggravate the wund r scar r that prduce r relieve trauma Burn Signs f infectin Wund characteristics Wund scar tissue characteristics Jint Integrity and Mbility Jint integrity and mbility Jint play mvements Specific bdy parts Mtr Functin Dexterity, crdinatin, and agility Electrphysilgical integrity Hand functin Initiatin, mdificatin, and cntrl f mvement patterns and vluntary pstures Muscle Perfrmance Electrphysilgical integrity Muscle strength, pwer, and endurance Muscle strength, pwer, and endurance during functinal activities Muscle tensin Neurmtr develpment and sensry integratin Acquisitin and evlutin f mtr skills Oral mtr functin, phnatin, and speech prductin Sensrimtr integratin

7 Orthtic, prtective, and supprtive devices Cmpnents, alignment, fit, and ability t care fr the rthtic, prtective, and supprtive devices and equipment Orthtic, prtective, and supprtive devices and equipment use during functinal activities Remediatin f impairments, activity limitatins, and participatin restrictins with use f rthtic, prtective, and supprtive devices and equipment Safety during use f rthtic, prtective, and supprtive devices and equipment Pain Pain, sreness, and nciceptin Pain in specific bdy parts Psture Pstural alignment and psitin (dynamic) Pstural alignment and psitin (static) Specific bdy parts Prsthetic requirements Cmpnents, alignment, fit, and ability t care fr prsthetic device Prsthetic device use during functinal activities Remediatin f impairments, activity limitatins, and participatin restrictins with use f the prsthetic device Residual limb r adjacent segment Safety during use f the prsthetic device Range f mtin (including muscle length) Functinal ROM Jint active and passive mvement Muscle length, sft tissue extensibility, and flexibility Reflex integrity Deep reflexes Electrphysilgical integrity Pstural reflexes and reactins, including righting, equilibrium, and prtective reactins Primitive reflexes and reactins Resistance t passive stretch Superficial reflexes and reactins Self-care and hme management (including activities f daily living and instrumental activities f daily living) Ability t gain access t hme envirnments

8 Ability t perfrm self-care and hme management activities with r withut assistive, adaptive, rthtic, prtective, supprtive, r prsthetic devices and equipment Safety in self-care and hme management activities and envirnments Evaluatin Sensry integrity Cmbined/crtical sensatins Deep sensatins Electrphysilgical integrity Ventilatin and respiratin Pulmnary signs f respiratin/gas exchange Pulmnary signs f ventilatry functin Pulmnary symptms Wrk (jb/schl/play), cmmunity, and leisure integratin r reintegratin (including instrumental activities f daily living) Ability t assume r resume wrk (jb/schl/plan), cmmunity, and leisure activities with r withut assistive, adaptive, rthtic, prtective, supprtive, r prsthetic devices and equipment Ability t gain access t wrk (jb/schl/play), cmmunity, and leisure envirnments Safety in wrk (jb/schl/play), cmmunity, and leisure activities and envirnments Evaluatin is a thught prcess that may nt include frmal dcumentatin. Hwever, the evaluatin prcess may lead t dcumentatin f impairments, activity limitatins, and participatin restrictins using frmats such as: A prblem list A statement f assessment f key factrs (e.g., cgnitive factrs, cmrbidities, scial supprt) influencing the patient/client status. Diagnsis Dcumentatin f a diagnsis determined by the physical therapist may include impairment, activity limitatin, and participatin restrictins. Examples include: Impaired Jint Mbility, Mtr Functin, Muscle Perfrmance, and Range f Mtin Assciated With Lcalized Inflammatin (4E) Impaired Mtr Functin and Sensry Integrity Assciated With Prgressive Disrders f the Central Nervus System (5E) Impaired Aerbic Capacity/Endurance Assciated With Cardivascular Pump Dysfunctin r Failure (6D) Impaired Integumentary Integrity Assciated With Partial-Thickness Skin Invlvement and Scar Frmatin (7C) Prgnsis Dcumentatin f the prgnsis is typically included in the plan f care. See belw. Plan f Care Dcumentatin f the plan f care includes the fllwing:

9 VISIT/ENCOUNTER Overall gals stated in measurable terms that indicate the predicted level f imprvement in functining A general statement f interventins t be used Prpsed duratin and frequency f service required t reach the gals Anticipated discharge plans Dcumentatin f each visit/encunter shall include the fllwing elements: Patient/client self-reprt (as apprpriate). Identificatin f specific interventins prvided, including frequency, intensity, and duratin as apprpriate. Examples include: Knee extensin, three sets, ten repetitins, 10# weight Transfer training bed t chair with sliding bard Equipment prvided Changes in patient/client impairment, activity limitatin, and participatin restrictin status as they relate t the plan f care. Respnse t interventins, including adverse reactins, if any. Factrs that mdify frequency r intensity f interventin and prgressin gals, including patient/client adherence t patient/client-related instructins. Cmmunicatin/cnsultatin with prviders/patient/client/family/ significant ther. Dcumentatin t plan fr nging prvisin f services fr the next visit(s), which is suggested t include, but nt be limited t: The interventins with bjectives Prgressin parameters Precautins, if indicated REEXAMINATION Dcumentatin f reexaminatin shall include the fllwing elements: Dcumentatin f selected cmpnents f examinatin t update patient's/client's functining, and/r disability status. Interpretatin f findings and, when indicated, revisin f gals. When indicated, revisin f plan f care, as directly crrelated with gals as dcumented. DISCHARGE/DISCONTINUATION SUMMARY Dcumentatin f discharge r discntinuatin shall include the fllwing elements: Current physical/functinal status. Degree f gals achieved and reasns fr gals nt being achieved. Discharge/discntinuatin plan related t the patient/client's cntinuing care. Examples include: Hme prgram. Referrals fr additinal services. Recmmendatins fr fllw-up physical therapy care. Family and caregiver training. Equipment prvided. Relatinship t Visin 2020: Prfessinalism (Practice Department, ext 3176) [Dcument updated: 12/14/2009]

10 Explanatin f Reference Numbers: BOD P stands fr Bard f Directrs/mnth/year/page/vte in the Bard f Directrs Minutes; the "P" indicates that it is a psitin (see belw). Fr example, BOD P means that this psitin can be fund in the Nvember 1997 Bard f Directrs minutes n Page 6 and that it was Vte 18. P: Psitin S: Standard G: Guideline Y: Plicy R: Prcedure