Where does it belong?
The client brought her notebook that she is implementing as her external memory aid.
What is subjective?
This section documents the data from the patient encounter.
What is objective?
at least 24 hours in advance you email these individuals to request protocols
Who are Tracy and J'ana?
official system to assign health care codes describing diagnoses and procedures in the United States
What are ICD-10 codes?
helps guide healthcare workers use their clinical reasoning to assess, diagnose, and treat a patient based on the information provided by them
What is a SOAP Note?
based on the client's performance in this session, this is what you will target next
What is plan?
The first heading of the SOAP note. Documentation under this heading comes from the experiences, personal views or feelings of a patient or someone close to them
What is subjective?
The cause of the squeaking sound sometimes heard in the clinic
What is the swing on the first floor?
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.
What is prior authorization?
Any data that can be measured with a numerical value
What is quantitative data?
The client will answer 10 personally relevant questions using written choice communication.
What is objective?
This section documents the analysis or interpretation of “subjective” and “objective” information. This is where you document the patient’s status through analysis of the target and changes in the status of the problems.
What is assessment?
the number of this "pop"ular game in the clinic, featuring a pirate or a dragon
What is five?
Pertinent background information, results, and interpretation of assessments and observations, prognosis, and recommendations for further assessment, follow-up, or referral, as appropriate
What are some essential elements of documentation?
Outcomes reported in non-numerical terms, using descriptions of performance or progress
What is qualitative data?
The client benefitted from additional placement cues compared to the previous session, indicating a need for more support in the next session.
What is assessment?
This section helps future clinicians understand what needs to be done next.
What is plan?
this instrument measures airflow from the nose and the mouth
What is the nasometer?
Medicare defines this term as "health-care services or supplies needed to diagnose, or treat an illness, injury, condition, disease, or its symptoms, and that meet accepted standards of medicine"
What is medical necessity?
You will include this statement in your evaluation report to indicate the predicted outcome of a client following treatment
What is prognosis?
The client skipped merrily into the treatment room where he remained seated throughout the entirety of the session.
What is not applicable?
Two acronyms that reflect general components of clinical documentation
CHARTS & MISS
DAILY DOUBLE - WHAT DO THESE ACRONYMS STAND FOR?
Tucked in a corner on a top shelf, nasal stethoscopes are one unique item in this room.
What is the sink room?
The individual's speech, language, cognitive, communication, and/or feeding and swallowing skills no longer adversely affect the individual's performance, health, and/or safety
This term refers to numbers, such as 92507, and phrases, such as "speech therapy treatment session" included at the end of every SOAP note
What is a billing code (or CPT code)?