attachment p note writing - Program in Physical Therapy

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ATTACHMENT

P

NOTE WRITING

I.

General Descriptions of Types of Notes PT's Write

A.

Initial Notes The initial note should contain all data obtained from evaluating the patient on his first visit. This includes the data and reason for referral, who referred the patient and medical diagnosis. A statement of chief complaints and other relevant information gleaned from the patient/patient's family are included. It must contain all of your objective findings from your evaluation. Also included is your assessment is a summary list of problems, recommended interventions, response to treatment provided, goals and plan. Documentation stating interventions initiated, what it consisted of, and level of patient participation/concurrence with PT plan should be included.

B.

Progress Notes Progress notes are written at a frequency determined by the patient's condition and by departmental policy. Progress notes should address new problems and information about any ongoing problems which are being treated. They should include exact measurements of changes from the initial evaluation, exact statements of treatment procedure (length of treatment, temperature or settings of equipment, positioning or equipment used in treatment) and of patient response to treatment (vital signs, skin changes, patient complaints etc.) Indicate whether consultation with other professionals (doctor, OT, prosthetist, etc.) has occurred and what the patient has been taught about his condition. Conclude by indicating the

plans for fuither treatment or discontinuation of treatment. Depending on the facility, attendance notes stating what treatment was done and how patient handled the treatment may be required for every P.T. session.

C.

Discharge Notes Discharge notes should summarizethe course of treatment, response and final status of the patient. There should be a comparison of the final status and initial condition. The reason for discharge or discontinuation, the disposition of the patient and follow-up plan for PT should also be included.

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II.

Format for Initial. Interim. and Discharge Notes The S.O.A.P. form is used in many hospitals to facilitate organization of relevant patient information, even if the Problem Oriented Medical Record system is not strictly enforced. S - subjective

O - objective

A - assessment P - plan

m.

General Format of an Initial Note

Initial note should include the following information prior to the S.O.A.P. component of the note: Date: Time in:

Patient is

Time out:

a

year old man/woman with the diagnosis of (date) for physical therapy

Dr. includine

,

referred by

Date of lnitiation: Date of Onset:

The patient has consent to be examined and evaluated. The following outline contains suggestions for inclusion under the headings in the S.O.A.P. format (initial, progress and discharge notes):

S:

Subjective Information (what you hear)

a.

Patient's description of his complaints, loss of function, pain and date of onset. patient cannot speak, note non-verbal communication.

If

b.

Relevant data obtained from interview with the patient and"/or family which cannot be verified from the medical record or previous treatment.

c.

Staternents taken from interviews with the family about the patient's problems or

condition.

d.

The patient's goals for him/herself

e.

Patient's prior level of function

f.

Patient's home environment

g.

If in out-patient, PMH

(past medical history obtained in the interview. Also include 76

[T1pe text] screening checklist information, medications, tests etc.

O:

A:

Objective Information (what you observe and do)

a.

Portions of patient's chart history relevant to the current problem and treatment in PT. This might include a summary of recent surgery, reason for admission and referral, laboratory reports or x-rays, but should be bne[. Many times "chart reviewed and PMH noted" is sufficient. also include any precautions or restrictions. Examples of precautions are weight-bearing status, medications, aspiration, fall risk etc.

b.

Results of your examination: listing all impairments and functional limitations tested, e.g. strength, sensation, anthropometrics, goniometry, edema, functional performance, observations that are specific regarding posture and quality of movements.

c.

Interventions performed: where, when, what, how long? This does not usually include the specific exercise used in treatment but rather the tlpe of exercise.

Assessment (what you think)

a.

Professional evaluation of overall impairments based on integration of the subjective and objective findings.

b.

Identify and interpret problems, relate to overall function.

1. 2.

Clarit'the problerns which physical therapy

can address. These may include impairments and/or functional limitations. List and number them, in order of

priority for treatment or severity. Specifu the (contributing factors) (impairments) which explain the problems on the problem list.

c.

List the diagnosis for physical therapy (or classification.)

d.

Patient's specific response to intervention: physical response to treatment (improved, unchanged, worsened), emotional reaction to treatment. Never document that the patient "tolerated treatment well." lnclude a statement of rehabilitation prognosis (excellent, good, fair, poor, guarded) for functional recovery and the deductions and expectations that support the prognosis (may not be required). These deductions are based upon moderating factors that are either positive or negative. ** Must document why patient needs continued physical therapy.

e.

P:

Plan (what you

will do)

a.

What PT treatment is planned - continue or change treatment.

b.

Progression of the plan.

c.

Education planned for patient/family.

d.

Differentiate and outline the short and long term goals in measurable terms and with time frames indicated. Long Term Goals must be functionally oriented (not focused on impairments.) Short Term Goals may focus on impairment or function, although Medicare requires all goals to be in functional terms. Also state that the patient participated in establishing the goals if they did.

e.

Estimate the exact expected length of time needed to realistically complete the treatment program.

f.

Frequency/duration of treatment.

g.

Follow-up

l.

Consultation with or referral to other professionals or agencies planned (if appropriate). 2. Anticipated needs after discharge: equipment, setting, 3. Informed consent: document that the patient has been informed of the findings and consents to further intervention as planned. (See specific format later in this handout.)

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IV.

"Service" Treatment Note - Inpatients

A brief note is written in the chart every time the patient is treated in order to meet requirements from third party payers and risk management and to improve continuity of care. Also as communication to other health care providers about patient's rehabilitation status. SOAP format may be used, but is not necessary. The date and the time the treatment was completed should be written in the margin. If the chart is unavailable and you have to write the note later, indicate the time you write the note in the left margin. The time the treatment occurred should be in the body of the note. The treatment administered should be listed. If the treatment follows a well-known protocol or has been stated in the initial note, just state the title of the treatment (ex: LE ROM, ADL Training, Speech/Language, Swallowing Therapy per plan). If the treatment deviates from protocol or the original plan, the difference should be stated along with the reason for a change. The patient's response to treatment is important. Patient complaints should be noted and/or your statement of how patient responded. Your staternent may include objective measures, i.e., BP, pulse, SOB. Any deviation from the expected response should be documented, as well as your follow-up. The active therapy plan should be designated clearly. Do not write "as above" or "continue per plan". State what the plan is.

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V.

Service Progress Note

Date:

S:

This includes pertinent data from the patient and/or family. May include comments the patient/family have made RE: progress, compliance to treatment plan, specific complaints, etc. If no comments were made, state that "patient voiced no concerns." DO NOT LEAVE THIS SECTION BLANK!

O:

Current Problem List: List existing problems only. Use abbreviated format. There is no need to list resolved problems. They should be listed in daily notes as they are resolved. Address the problerns that is/are of concern, i.e. dressing, gut, swallowing. Provide objective measures of progress. Note: Each problem should be addressed at least one time per month.

Treatment provided: Describe the interventions provided to the patient.

A:

Professional opinion of how patient is doing and why they would benefit from continued therapy. Review status of goals. List goals currently being addressed. State any goals that have been achieved. Be brief. You do not have to re-state entire goal in behavioral terms. Restate in abbreviated form, i.e. gait, ROM, dressing.

Any new problems that may be identified during therapy should be listed here. New problems are numbered and added seque'ntially to the existing problem list.

P:

Any new goals should be listed here. If goals are added or a change in the treatment plan is *ud", a statsment of patient participation is needed. Time frames for achievement of additional goals should also be included. Signature: Phone/Beeper:

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VI.

"Seryice"Initial-DischareeNote Date:

Patient with (Djasnosis) referred by Dr.

@)

on (Date) for (84-p!4).

DATE OF SERVICE: (If different than above)

S:

(PMH perpt)

O:

PMH: per chart Evaluation results Treatment provided

A:

Brief summary of findings of the evaluation and the patient's limitations. Rehab Proenosis:

Problem List

P:

Patienflpt's family participated/unable to participate in establishing the following goals and plans. treatment sessions)

Goals: (to be achieved itt Treatment Plan:

-

Patient discharged/discontinued secondary to : Discharge Plan/follow-uP

:

Signature: Phone/Beeper

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VII.

PT ConsultNote

Date of visit

Patient is a _

year old man/woman with the diagnosis of on _(date) for physical therapy

referred by

including

S:

Pertinent data from patient and./or family.

O:

Screening results.

A:

Summary of status per screening.

P:

Any follow-up.

EX: "No interyention indicated." or "Will obtain referral for (seirrice) "evaluation and treatnent.

u

Therapist: Date: Phone:

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Additional Guidelines for Specific Sections of the Note Infarmed Consent

-

fundamental right in case law, by statute or as a matter of customary practice required by APTA and accreditation standards

Checklist Disclosure Elements for Patient Informed Consent to Treatment - Diagnosis or evaluative findings - Description of the recommended treatment - Material (decisional) risks/foreseeable complications/precautions associated with the proposed treatment - Prognosis if the treatment is carried out - Reasonable altematives to the proposed treatment, and attendant risks and prognosis if an alternative treatment is used - Solicit and answer the patient's questions about treatment Documenting Informed Consent 1. consent forms 2. documentation if treatment records 3. use of informed consent checklists 4. reference to standard operating procedures or clinic policy staternents Example from Legal Aspects of Documentation by Ronald Scott, page 144:

Pt. verbqlizes/demonstrates understanding of pt.'s diagnosis, proposed treqtment program, major risl