Fichas
Documentation
Fichas del conjunto (20)
- 1Documenation* Done daily (often)
* All healthcare professionals
* SOAP format most common
* Integral part of patient care process
* Significant time spent documenting daily - 2Reasons to Document* Legal
* Communication
* Reimbursement
* Decisions regarding Discharge
* Helps organize therapist thoughts
* Use for Quality Assurance
* Research - 3Medical Record & Notes* Legal Document can be subpoenaed
* Never record false info, exaggerate, or make up data
* Note about Patient NOT therapist
* Concise, use of abbreviations, legible, clear, not vague - 4Medical Record & Notes continued...* Don't use hyphen except with ROM
* Semicolon and colon OK
* No blank lines between entry
* Sign all notes with full name and initials
* No "white out" or cross out or blacken anything written (use single line then initial above) - 5"S" = Subjective* Pt. relates hx
* Pt tells of lifestyle or home situation
* Pt. tells what he/she can no longer do
* Voices complaint
* States goals
* Expresses emotions or response to treatment
(Mood, focus, cooperation, energy level, pain level, quotes from Pt & family; "How it feels") - 6"S" = Subjective continued...* Anything the pt expresses (concerns) that is/are relevant to the patient's case or present condition.
* Use pt.
* Organize subcategories
* Quote patient to illustrate point
* Can use family member information - 7"O" = Objective What went on during treatment. Chronologically if necessary.* Measurable and observable
* Therapist results of measurements
* Provides info on what was done with pt on specific date
* Important for Reimbursement & legal reasons (must show need for skilled occupational therapy) - 8"O" = Objective continued...* Appropriate terminology
* Correct spelling
* Organize information so easy to read and understand; flows
* Headings based on tests & measurements
* Headings based on areas of body - 9"O" = Objective COMMON MISTAKES* Fail to state affected body part
* Fail to use measurable terms
* Fail to state what is being measured (ex. flexion of Right UE)
* BE VERY SPECIFIC - 10"A" = Assessment* Includes everything from "S" and "O" that is not WNL (List of problems)
* STG = short term goals
* LTG = long term goals
* Drawing conclusions & justifying decisions
* Identify inconsistencies
* Discussion of pt progress in therapy
* Suggest further testing, treatment, etc. - 11"A" = Assessment continued...Questions to ask examples:
1. Is pt better/worse today?
2. Did ROM increase/decrease?
3. Is pt showing progress/plateauing?
4. Do you need to rewrite goals? - 12"P" = PlanPlan For Therapy:
* Tells time and frequency of therapy ( 60 min per day/ 5 x per week/ 3 weeks)
* Tells treatment pt will receive - 13Functional Maintenance ProgramProgram developed for clients discharged from therapy but remain in skilled nursing facility.
Program facilitates skills present but not utilized unless compensations or adaptations are provided. - 14Informed ConsentLegal and ethical communication process between client and clinician that results in the client's authorization or permission to participate in evaluation and intervention.
- 15Medical NecessityIntervention is consistent with the diagnosis, and failure to provide intervention would jeopardize or significantly compromise the client's condition or quality of medical care.
- 16Negative Prognostic IndicatorsSigns that indicate barriers inhibiting rehab potential.
- 17Positive Prognostic IndicatorsIndicators that the client has good rehab potential, which is essential for third-party reimbursement.
- 18Restorative ProgramsPrograms that facilitate the learning of new skills in an attempt to "restore" the client's previous abilities.
- 19ScreeningProcess of determining if a client requires the skilled services of an OT practitioner.
Helps to identify changes in functional status such as improvements or declines in physical or cognitive abilities. - 20Standardized AssessmentsMethods used for data collection that have established reliability and validity.
Información
- Descripción
- El usuario ha eliminado su información de asignaturas Fichas sobre Documentation, creado por Usuario eliminado el 01/12/2018.
- Creado por
- Usuario eliminado · dic 2018
- Actualizado
- 1 dic 2018
- Visitas
- 12
- Historial
-
- Creado por Robin Decker · 6 oct 2018
- Copiado por Robin Decker · 1 dic 2018
- Valoración