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Documentation Review Sample Checklist REVIEW FOR MEDICAL RECORDS DOCUMENTATION

Physical Therapy Note: This is meant to be a sample documentation review checklist only. Please check payer, state law, and specific accreditation organization (i.e., Joint Commission, CARF, etc) requirements for compliance. Therapist reviewed: Privileged and Confidential PT Initial Visit Elements for Documentation Date: N/A Yes No Examination:

1. Date/time

2. Legibility

3. Referral mechanism by which physical therapy services are initiated

4. History – medical history, social history, current condition(s)/chief complaint(s), onset, previous functional status and activity level, medications, allergies

5. Patient/client’s rating of health status, current complaints

6. Systems Review – Cardiovascular/pulmonary, Integumentary, Musculoskeletal, Neuromuscular, communication ability, affect, cognition, language, and learning style

7. Tests and Measures – Identifies the specific tests and measures and documents associated findings or outcomes, includes standardized tests and measures, e.g., OPTIMAL, Oswestry, etc.

Evaluation:

1. Synthesis of the data and findings gathered from the examination: A problem list, a statement of assessment of key factors (e.g., cognitive factors, co- morbidities, social support, additional services) influencing the patient/client status.

Diagnosis:

1. Documentation of a diagnosis – include impairment and functional limitations which may be practice patterns according to the Guide to Physical Therapists Practice, ICD9-CM, or other descriptions.

Prognosis:

1. Documentation of the predicted functional outcome and duration to achieve the desired functional outcome

Plan of Care:

1. Goals stated in measurable terms that indicate the predicted level of improvement in function

2. Statement of interventions to be used; whether a PTA will provide some interventions

3. Proposed duration and frequency of service required to reach the goals (number of visits per week, number of weeks, etc)

4. Anticipated discharge plans

Authentication:

1. Signature, title, and license number (if required by state law)

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PT Daily Visit Note Elements for Documentation Date: N/A Yes No

1. Date

2. Cancellations and no-shows

3. Patient/client self-report (as appropriate) and subjective response to previous treatment

4. Identification of specific interventions provided, including frequency, intensity, and duration as appropriate

5. Changes in patient/client impairment, functional limitation, and disability status as they relate to the plan of care.

6. Response to interventions, including adverse reactions, if any.

7. Factors that modify frequency or intensity of intervention and progression toward anticipated goals, including patient/client adherence to patient/client-related instructions.

8. Communication/consultation with providers/patient/client/family/ significant other.

9. Documentation to plan for ongoing provision of services for the next visit(s), which is suggested to include, but not be limited to:

The interventions with objectives

Progression parameters

Precautions, if indicated

10. Continuation of or modifications in plan of care

11. Signature, title, and license number (if required by state law)

PT Progress Report Elements for Documentation ** Date: N/A Yes No

1. Labeled as a Progress Report/Note or Summary of Progress

2. Date

3. Cancellations and no-shows

4. Treatment information regarding the current status of the patient/client

5. Update of the baseline information provided at the initial evaluation and any needed reevaluation(s)

6. Documentation of the extent of progress (or lack thereof) between the patient/client's current functional abilities/limitations and that of the previous progress report or at the initial evaluation

7. Factors that modify frequency or intensity of intervention and progression toward anticipated goals, including patient/client adherence to patient/client-related instructions.

8. Communication/consultation with providers/patient/client/family/ significant other

9. Documentation of any modifications in the plan of care (i.e., goals, interventions, prognosis)

10. Signature, title, and license number (if required by state law)

** The physical therapist may be required by state law or by a payer, such as Medicare, to write a progress report. The daily note is not sufficient for this purpose unless it includes the elements listed above.

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PT Re-examination Elements for Documentation Date: N/A Yes No 1. Date

2. Documentation of selected components of examination to update patients/client's impairment, function, and/or disability status.

3. Interpretation of findings and, when indicated, revision of goals.

4. Changes from previous objective findings

5. Interpretation of results

6. When indicated, modification of plan of care, as directly correlated with goals as documented.

7. Signature, title, and license number (if required by state law)

PT Discharge/Discontinuation/Final Visit Elements for Documentation Date: Note: discharge summary must be written by the PT and may be combined with the final visit note if seen by the PT on final visit

N/A Yes No

1. Date

2. Criteria for termination of services

3. Current physical/functional status.

4. Degree of goals and outcomes achieved and reasons for goals and outcomes not being achieved.

5. Discharge/discontinuation plan that includes written and verbal communication related to the patient/client's continuing care.

6. Signature, title, and license number (if required by state law)

PTA Visit Note Elements for Documentation Date: N/A Yes No 1. Date

2. Cancellations and no-shows

3. Patient/client self-report (as appropriate) and subjective response to previous treatment

4. Identification of specific interventions provided, including frequency, intensity, and duration as appropriate

5. Changes in patient/client impairment, functional limitation, and disability status as they relate to the interventions provided.

6. Subjective response to interventions, including adverse reactions, if any

7. Continuation of intervention(s) as established by the PT or change of intervention(s) as authorized by PT

8. Signature, title, and license number (if required by state law)

Patient is a 42-year-old male complaining of point tenderness and point on both lateral epicondyles at a PAS of 6/10. The pain began 3 months ago while the patient was weight training and reported excess fatigue after exercises involving the wrist joint. Pain progressively increased leading to difficulty with gripping tasks, opening door knobs and jars, pain when gripping handlebars while cycling, and gripping the steering wheel. This led patient to an MD consult and was referred by the DC to PT for further examination and treatment. The patient who has been independent and pain free without any functional limitations now presents to PT with limited ability to perform any gripping tasks, lateral epicondyle pain when opening door knobs and jars, pain when gripping handle bars while cycling and gripping the steering wheel due to pain and tenderness upon muscular contraction of the wrist dorsiflexors. No imaging was performed, no relevant past medical history noted. Patient is taking an NSAID PRN for pain. Upon ocular inspection, there was no notable swelling or redness on the lateral epicondyles and surrounding areas. There was palpable tenderness about 1 cm distal to the common extensor insertion on both sides. ROM and MMT for the elbow and forearm where within normal limits except for pain during wrist dorsiflexion on both sides with pain manifesting at the lateral epicondyles of both sides. PT took the patient to the exam room door knob and confirmed tenderness and pain upon pronation and supination wherein after we discussed changing the angle of approach and the use of variable wrist positions to accommodate the current symptoms. The patient felt reduced symptoms with position modification which will allow him to manipulate doors for the meantime. We utilized grip extenders used in manipulating barbells to check occurrence of lateral epicondyle pain when managing handlebars. We noted that the slimmer the grip, the more pain is felt. Thickening/building up the grip reduced symptoms. We used a Pilates ring to confirm pain during steering wheel modification. Due to the improvement with the thicker handle in the earlier test, we modified grip use as well. We discussed the purchase of a steering wheel wrap to increase the diameter of the steering wheel to allow ability to use the device for the meantime. DASH score is 25. Grip test revealed 35 kg force on the right and 32 kg force on the left. There is a positive Cozens test on both sides, a negative Golfer’s elbow test on both sides. The patient is experiencing symptoms synonymous with tendinopathy of both wrist extensors along the common extensor origin as manifested by pain, tenderness, especially during wrist dorsiflexion and pronation affecting wrist and forearm strength and use in daily activities such as door knob and steering wheel manipulation. Skilled physical therapy is necessary to gradually decrease functional difficulty and improve essential ADL such as difficulty due to pain during gripping tasks, lateral epicondyle pain when opening door knobs and jars, pain when gripping handle bars while cycling and gripping the steering wheel, improve wrist and elbow strength and stability, and the need to return to the highest practicable level of function. In addition skilled therapy is necessary to monitor performance of therapy and patient reactions due to biomechanical issues that may lead to injury, history of previous frozen shoulder, and response to the individualized therapy regimen. Goals Patient will report decreased pain while performing functional tasks such as difficulty due to pain during gripping tasks, lateral epicondyle pain when opening door knobs and jars, pain when gripping handle

bars while cycling and gripping the steering wheel and similar activities with 1- 2point change in two weeks, to a 2-3 point change in four to six weeks on the Numeric Pain Rating Scale. (MCID for musculoskeletal pain – 1 point or 15.0% change, for Lower Back Pain: (Childs et al, 2005)- at 1 week of physical therapy treatment = 1.5 points, at 4 weeks of physical therapy treatment = 2.2 points) Patient will be able to perform dressing for uppers, ability to sustain counter top activities, shoulder height and overhead reaching, use cycling handlebars, steering wheel during driving exhibiting 5/5 muscle strength on both elbow and wrist muscle groups, with minimal pain within 8 weeks of therapy.

Patient will report greater than or equal to a 10.2 point improvement in the Disabilities of the Arm, Shoulder and Hand index scores (Schmitt J.S., Di Fabio R.P., 2004) MCID = 10.2 in 8 weeks of therapy. This point improvement represents a significant change in the symptoms and severity of musculoskeletal disorders of the patient’s upper limbs. The DASH evaluated two modules used to measure symptoms and function in adults who require a high level of function.

Skilled Intervention

Therapist guided and modified strength training as well as facilitated joint mobilization for normalization of joint mechanics on both elbow and wrist joints is essential. Skilled therapy is necessary to achieve the full potential of joint play around the both elbow and wrist joints. The therapist determines abnormal biomechanical interplay between the joint surfaces and the surrounding ligaments, joints in consideration of pathologic factors and its effects. Achievement of normal joint play would allow the individual to be able to move in all ADL necessary planes and directions permitted to that joint – necessary for not just general health, but injury prevention, and activity performance. Factors that may complicate this therapy plan that requires skilled observation include pain, swelling, and stiffness in the joints. Delaying treatment can have long lasting effects on the freedom of joint movement and lack of therapy can delay progress and lead to deterioration of movement necessary for quality of life. Factors that affect this patient’s joint play current joint structure, muscles, tendons, ligaments, activity level, gender, age, and genetics.

Patient care and goals were discussed with patient, consent was given and therapy will be performed 2x per week for 8 weeks with the following plan

Pain Peripheral joint mobilization Strengthening Increasing forearm strength and endurance. PROM-> AAROM-> AROM -> RROM to focus on use of eccentric strengthening. The theory behind eccentric strengthening is to load the musculotendinous unit inducing hypertrophy and increasing tensile strength. This in turn reduces the strain on the tendon during activities. Eccentric contraction can create a greater stimulus for the cells of the tendon, producing collagen and resulting in the tendon being able to withstand greater forces. Improving Range of Motion Mobilization performed in combination with strengthening programs. Mobility programs for lateral epicondylitis focuses on the wrist extensors musculature. Stretching should be performed by bring the wrist into flexion with the elbow in full extension, forearm pronated and placing overpressure with the other hand allowing a stretch to be felt at the common extensor tendon. Studies also suggests patient

should perform stretching with shoulder at 90 degrees flexion and should be performed twice a day, three repetitions with a 30 second hold followed by a 30 second rest before next repetition.

Home Exercise Home Exercise programs should be based on strengthening and stretching programs performed in the clinic setting. Progression and sets should be based on patient tolerance to exercise and relief of symptoms. RKLBaloy, PT, DPT, EdS, MS

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