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Who are some people that may read a patients PT record?
therapist, physician, insurance, lawyers, nurses, billing, social workers
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Why would other professionals want to read a PT chart?
progress, see what has been done and who did it, measurements, treatments to do, precautions/restrictions, costs, health changes, why treatment is being done etc....
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When documenting, who must the PTA keep in mind and why?
the reader (audience); readers are each interested in different pieces of information
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Why is documentation significant?
evidence of patient care, accountability of patient care, importance of documentation
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Documentation is written proof that what was given to the patient?
medical care
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Under evidence of patient care, what is the "motto"?
"if it isnt written, it didnt happen"
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Accountability of patient care hold who responsible for the care provided?
holds YOU (the provider of care) responsible
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Accountability of patient care allows 3rd party payers what 3 things?
value of care provided, effectiveness of treatment, and medical necessity of the treatment
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When documenting, what must you provide?
lots of details
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What is the quality of physical therapy care?
care that follows the standards of practice for PT published by the APTA
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Records of the quality of care allows for what?
communication between the medical team members
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What 4 things are regarded during communication of a record of quality care for a patient?
- 1. identification of patients problem
- 2. solutions
- 3. plans for patients discharge
- 4. coordination of the continuum of care
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What 3 reasons are medical records reviewed or audited?
- 1. quality assurance
- 2. research and education
- 3. reimbursement
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Whos documentation standards and criteria should you follow?
the facility where you work
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The documentation you make becomes a legal record, if called to testify in court, how do you want your documentation?
clear and accurate
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What can be denied if documentation is not clear and provide rationale to support care provided?
payment
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