What must documentation prove of the treatment?
What does SOAP stand for?
- objective (numbers, measurements)
- plan (next step, where are you heading)
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
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
What 3 things should you consider when writing in a medical record?
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
How do you sign your charts as a student?
Jami R. Powell, student PTA/
When there is space left on a line, what should you do?
put a line thru it as you would a check
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
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
What is data collection?
performing tests and recording results
When you leave a section out of your patients chart, what do you use to add it?
What is an addendum?
another not placed immediately behind the original note (end with "this portion of the note was unintentionally ommitted)