Medical

Documentati
on
Department of Physiotherapy
FAHS
UOP
 The student should be able
to
• Describe and perform basic
documentation skills
• Describe steps of history taking of
a patient
Intended • Perform effective history taking a
Learning patient referred for PT
• Describe principles of patient
Outcomes management
• Perform effective management of a
patient referred for PT
Good documentation promotes
patient safety and quality of care.

Complete and accurate medical

recordkeeping can help ensure that
your patients get the right care at the
right time.
Communicates with other health
care personnel
Medical notes should be always available to those giving
input to the patient and should be stored appropriately.

The current admission should be filed chronologically in the

correct section of the notes.

Each page must show the patient’s name, date of birth and a
unique identifier.

All entries should be dated and timed with the 24-hour clock.

Each entry should be concluded with the signature, printed

name and designation of the person making the entry, as
well as a contact number.
The content of the entry should be structured and legible.
Medical Documentation
Includes

 Assessment
 Examination
 Evaluation
Assessment

The process used to learn about a patient’s condition.

This may include
-A complete medical history,
-Medical tests,
-Physical exam,
-Tests to find out if the patient can carry out the tasks of daily
living,
-A mental health evaluation
-Review of social support and community resources available to the
patient.
-occupational health settings
Examination

 A detailed evaluation conducted by a physical therapist.

 Involves tests, measurements, and observations.
 Aims to identify the cause of symptoms or functional impairments.
 Leads to a diagnostic classification of the patient's condition.

The examination has three components:

▪ Patient/client history
▪ Systems reviews
▪ Tests and measures.

These are used to inform the clinical reasoning process.

 A dynamic process where the physical therapist makes clinical
Evaluation judgments based on examination data
.
•Involves ongoing assessment and decision-making.

•Requires re-examination to evaluate progress toward goals.

•Helps determine if the treatment plan needs modification or

changes.

•Focuses on tracking outcomes and adjusting care accordingly.

 A comprehensive review of the patient’s medical record,
Prior to see including the physician’s notes on the medical history, current
history, physical findings, and diagnosis; test results;
the patient • The physician’s request for treatment; nursing notes
• Medications prescribed, and any consultations to other
medical/ surgical specialties

Before Assess/ Examine/evaluate, Patient should be

oriented
 This is the process the therapist or caregiver uses to orient the
Patient patient about the condition and treatment plan/plan of care (POC)

Orientation
▪ Consists of
-Personal introduction /Greeting
-Informing the patient of the treatment goals
-Desired outcome, and potential risks
-Interviewing the patient (as part of the examination and
evaluation) to obtain information, and instructing the patient
regarding participation

You should be aware of the cultural diversity and should be able to

communicate appropriately to culture
 A process in which patients are given important information,
Informed including possible risks and benefits, about a medical procedure
or treatment, genetic testing, or a clinical trial.
Consent The caregiver is responsible for informing about the proposed
treatment, alternative treatments, and associated primary
known risks. The patient then has the right to consent to or
reject the proposed treatment
The patient must be able to understand the information.
Language that are comprehensible.
A translator or an interpreter may be required for persons who
do not speak or comprehend the language.
If a family member agrees to interpret for the patient, this
accommodation should be documented in the medical record
For patients who have not reached the legal age of consent and
for those judged to be mentally confused or incompetent to
participate – surrogate ( parent, guardian, family member, or
court -appointed advocate)

Failure -----------professional negligence.

If the patient refuses treatment, the refusal should be entered in

the medical record and accompanied by the reason given for the
refusal. The action taken by the caregiver also should be entered
  The documentation of patient care is an important component
of the written record maintained for each patient.
 It helps to communicate effectively between professions and
perform patient care effectively

 The physical therapist clearly documents all aspects of the

Documentation patient/client management, including
 The results of the initial examination/assessment and evaluation
 Diagnosis, prognosis/plan of care, intervention/treatment
 Response to interventions/treatment, changes in patient/client
status relative to the interventions/treatment
 Re -examination and discharge/discontinuation of intervention,
and other patient/client management activities
 ▪ Initial examination/ evaluation
Elements of
▪ Visit/encounter
documentation
▪ Reexamination
(APTA)
▪ Discharge or discontinuation summary
 1.The patient’s primary diagnosis and treatment
2. Physician’s orders
3. The patient’s barriers to treatment and their resolution
Components of
4. The patient’s consent to treatment
documentation 5. The plan of care, which includes goals (short and long term),
interventions, proposed frequency and duration, and discharge
6. Risk or benefit of treatment
Manual record management system

Electronic record management system

Hybrid system
 POMR -Problem oriented medical records ▪ Lawrence
Weed developed the concept of the problem oriented
Formats of medical record (POMR)
Documentation
SOAP Assessment
POMR - 1. Formation of a database (current and past
information about the patient)
Problem 2. Development of a specific, current problem list
oriented (problems to be treated by various practitioners)
3. Identification of a specific treatment plan
medical (developed by each caregiver)

records 4. Assessment of treatment plan effectiveness

 Information about the patient and the plan of care is contained
in the status notes, which are written in the SOAP format:

-Subjective
-Objective
-Assessment
-Plan

For each problem defined, a SOAP note must be recorded.

 ▪ Subjective
Primary complaint
POMR- Current illness (HPI)
Problem Previous medical history

oriented Previous surgical history

Current medications
medical Family history
records and Social history

SOAP Review of body systems

Treatment plan or physiotherapy techniques which will
be carried out during the next visit to achieve the set
goals
 Examination of the patient

Evaluation of the data and identification of

problems

Determination of the physical therapy diagnosis

and prognosis
Steps in
patient/client Determination of the POC (plan of care)
management
include Intervention

Reexamination and evaluation of treatment

outcomes
 Examination involves
 identifying and defining the patient’s impairments,
 activity limitations and restrictions in participation
 resources available to determine appropriate intervention
Examination  Patient History
 Systems review
 Tests and measures
 Task analysis
  Information is gathered from the patient or by
bystander/relative for the following components
 Primary complaint
 Current illness (HPI)

History  History of the presenting complaint

 Previous medical history
Taking  Previous surgical history
 Current medications
 Family history
 Social/ Socioeconomic history
  Active listening
Factors  Empathy
related to  Building rapport

effective  Asking appropriate questions

 Summarizing and validating patient responses
history  Non-verbal communication
taking  Careful observation during interview

/effective
patient
involvemen
t
Two types of questions can be used

1.Open ended questions (e.g., What symptoms are you currently

experiencing?
2.Closed ended questions (e.g., Do you have any pain today?)
  Questions which are posed regarding the history
Types of of the present illness or condition.

questions in  Questions then explore location, quality, and

severity of the symptoms or problems as well as
History timing (occurrence)
 factors that aggravate or relieve them, and
Taking associated manifestations.
 Questions are which are posed regarding
functioning
 Questions are also posed regarding the patient’s
past medical history, health habits (e.g., smoking
history, alcohol use), family history, and personal
and social history
Information about
physical environment
Vocation
recreational interests
exercise likes and dislikes, and type, frequency,
in tensity of regular activity should be obtained
Patient information can also be obtained from the
patient’s family or caregiver.
What problem(s) brings you to therapy?
When did the problem(s) begin?
What happened to precipitate the problem(s)?
How long has the problem(s) existed?
How are you taking care of the problem(s)?
What makes the problem(s) better?
What makes the problem(s) worse?
Are you seeing anyone else for the problem(s)?
 Screening questions are used to identify are of intact function and
dysfunction of following systems
MSK Neuromuscular
System Cardiovascular/pulmonary.
Review Integumentary
Communication ability, affect, and
language Cognition
Test and measures can be used to obtain information related to
▪ Level of Impairment
▪ Level of function and dysfunction
 Categories of test and measures

Tests and 

Anthropometric measurement
Muscle performance assessment
Measures  Cardiovascular assessment
 Balance assessment
  The data gathered during examination are synthesized to
identify impairment, activity limitation, and participation
restriction.
Evaluation
 The therapist uses this information to identify problems faced
by the patient and develop a problem list
  Medical

Diagnosis
 Physiotherapy
To the identification of a disease,
disorder, or condition Medical
(pathology/pathophysiology) Diagnosis
primarily at the cellular, tissue, or
organ level
PT diagnosis typically includes the
level of impairment activity
Physiotherapy
limitation participation Diagnosis
restrictions.
 Eg – 1
▪ PT diagnosis: Impaired motor function and sensory integrity
affecting the left non -dominant side with dependent functional
mobility and ADL.
▪ Medical diagnosis: Cerebrovascular accident

 Eg - 2
▪ PT diagnosis - Impaired ROM and Muscle strength
in L -U/L with redistricted overhead activity and inability to
participate in sport related activities
▪ Medical diagnosis -Rotator cuff tendinopathy
Prognosis The term prognosis refers to the predicted optimal level of
improvement in function and amount of time needed to reach that
level.
 The POC outlines anticipated patient management POC should
consists of
• Goals and expected outcome

Plan of Care • Prognosis

• a general statement of the interventions to be used, including
proposed duration and frequency required to reach the goals
• Discharged Plan
 • Patient identified outcome (PIP)
• Non patient identified outcome (NPIP)

Types of
outcome Goal statement should be
• Measurable
• Functionally driven
• Time limited
Goals describe the intended impact on functioning established with
specific time limits ▪ Four essential elements of a goal
▪ Individual
▪ Behavior/Activity
▪ Condition
▪ Time
Outcomes describe the predicted level of optima improvement
attained at the end of the episode of care or rehabilitation stay.
 Interventions include various physical therapy procedures and
techniques to produce changes in the condition that are consistent
with the diagnosis and prognosis.
Eg, ▪
Patient or client instruction
• Airway clearance techniques
• Assistive technology: prescription, application, and, as appropriate,
fabrication or modification
Interventions • Biophysical agents
• Functional training in self-care and in domestic, education, work,
community, social, and civic life
• Integumentary repair and protection techniques
• Manual therapy techniques
• Motor function training
• Therapeutic exercise
 Discharge planning is initiated early in the rehabilitation process
during the data collection phase and intensifies as goals and
expected outcomes are close to being reached.
Discharge planning may also be initiated if the patient refuses
Discharge further treatment or becomes medically or psychologically unstable

Plan In the discharge summary, the therapist should include current

physical/functional status, degree of goals/ outcomes achieved
▪ Reasons for goals/outcomes not being achieved
 Discharge prognosis. This is typically alone -word response such as
excellent, good, fair, or poor
  This step is ongoing and involves continuous reexamination of
the patient and a determination of the efficacy of treatment.
 If the patient attains the desired level of competence for the
stated goals, revisions in the POC are indicated.
Reexaminatio  If the patient attains the desired level of competence for the
expected outcomes, discharge is considered.
n  If the patient fails to achieve the stated goals or outcomes, the
therapist must determine why it is not achieved.
 Additional information is sought, goals modified, and different
treatment interventions selected.
Questions