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What must documentation prove of the treatment?
medical necessity
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What does SOAP stand for?
- subjective
- objective (numbers, measurements)
- assessment
- plan (next step, where are you heading)
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What do SOAP notes communicate?
- S - results of patients interview
- O - objective measurements done
- A - therapists assessment of the patients condtion
- P - therapists and patients goals for the patient and the plan of treatment
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What is a progress note?
an interim note a PTA must write after seeing a patient for a certain period of time to note any changes since the intial note was written
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What 3 things should you consider when writing in a medical record?
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What is the proper way to correct a mistake when writing in a chart?
single line, intial and date the error and write in correct words as close as possible
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How do you sign your charts as a student?
Jami R. Powell, student PTA/
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When there is space left on a line, what should you do?
put a line thru it as you would a check
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What does a discharge evaluation include?
- summary of tx
- relevant subjective data
- interpretation of objective tests
- effectiveness of tx (goals met)
- further recommendations
- follow up plans
- signature, title and license # of PT
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What is a discharge summary?
when a patient stops showing up. PTA writes up a summary note of care given, patients response, and functional status of pt
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What is data collection?
performing tests and recording results
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When you leave a section out of your patients chart, what do you use to add it?
an addendum
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What is an addendum?
another not placed immediately behind the original note (end with "this portion of the note was unintentionally ommitted)
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