Physical Therapy Documentation: From Examination to Outcome (10 contact hours) (#810)

Description

This course contains the most up to date and relevant tools for clinical documentation in physical therapy for survival in today’s health care environment. The course includes the text entitled Physical Therapy Documentation: From Examination to Outcome (2nd ed) by Mia Erickson, PT, Ralph Utzman, PT, and Rebecca McKnight, PT, copyright 2014. This course not only provides the basics for documentation, but most importantly benefits more seasoned therapists who have been in the field, because of its integration of evidence based practice into documentation. New clinicians as well as experienced clinicians will benefit from the information on improving documentation quality in the areas of skilled care and medical necessity. Practice problems (case studies) are included that range from simple to complex within varied practice settings. This is a must course for ALL PTs and PTAs who need to update their documentation skills in order to comply with current Medicare and other insurance reimbursement rules.-------------------------------------------------------------------------------------------------------------------------------------------------------------------------***COURSE OBJECTIVES***At the completion of this course, the physical therapy clinician will be able to: 1. Differentiate between pathology, activity limitation, and participation restriction. 2. Know the disablement model currently recommended by the APTA and list components required for appropriate documentation. 3. List reasons for documenting in physical therapy. 4. List criteria for determining if an intervention is reasonable and necessary. 5. Define skilled care. 6. Compare and contrast law, regulation (rules), and policies. 7. Explain how APTA’s Code of Ethics addresses documentation issues, such as informed consent, confidentiality, reimbursement, fraud and abuse. 8. Explain the purpose of incident reports and identify how they should be filed. 9. Discuss HIPPA laws and how they relate to PT. 10. Differentiate between evaluation and examination. 11. Compare and contrast narrative notes, problem oriented notes, SOAP notes and functional outcomes reports. 12. Differentiate between information found in the different sections of the SOAP note. 13. Identify current legislation regarding electronic medical records and list positive and negative aspects of electronic medical records. 14. Differentiate between the terms “late entry” and “addendum”. 15. Identify when a statement in a medical record is irrelevant, missing necessary components (such as showing skilled care), or appropriate. 16. Differentiate between the problem and subjective sections of the note and identify what types of data should be recorded in each. 17. Identify the components required in a Review of Systems. 18. Differentiate between measurements of impairments of body structure/function and measurements of functional activity limitations. 19. Differentiate between medical diagnosis and physical therapy diagnosis, and evaluation and examination. 20. Identify necessary components of the assessment portion of the SOAP note when documenting a PT evaluation. 21. Identify the necessary components of a well written goal. 22. Explain how a PT can integrate evidence regarding tests and measures into goal statements. 23. Differentiate between a treatment note and a progress note; differentiate between a reassessment and a reevaluation. 24. Identify factors that would indicate a need for a reevaluation. 25. Define outcome. 26. Identify necessary components of a discharge summary. 27. Identify payment models used by Medicare in the acute care hospital setting, inpatient rehab facility, skilled nursing, home health, and outpatient. 28. Identify responsibilities for documentation by the PT and PTA under Medicare. 29. Identify the system used to code both medical diagnosis and treatment services. 30. Apply the correct physical therapy billing code and units to a case study.

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