What belongs
Patient states maternal grandmother has history of myocardial infarction and high blood pressure.
family health history
Which ROS category do muscle cramps, joint pain, weak muscles, joint swelling, neck pain, and back pain fall under?
Musculoskeletal system
2 things all notes should have
date and signature
The final progress note that can include updates of the patient's status
discharge note
Patient reports being left handed.
Demographic information
Which ROS category do chest pain, heart palpitations, heart murmurs, high blood pressure, and leg cramping fall under?
Cardiovascular system
Best practice timing for when to document
at time of visit when possible
Helps other health professionals find information in your note
Headings and subheadings
Patient reports exercising 4 days a week, at moderate intensity for 60 minutes a day.
social/health habits
Which ROS category do chronic dry cough, cough with mucus, coughing up blood, pneumonia, and night sweats?
Respiratory system
When should discharge planning occur?
throughout the episode of care
APTA stance on abbreviation use
The APTA cautions against use of too many abbreviations
Developmental information, typically applicable to pediatric patients
growth and development
Purpose of reviewing ROS information with patient
to ensure thoroughness and accuracy
3 examples of information included in a complete history
Medical/surgical history, social history, growth and development, living environment, work status, cultural preferences, previous and current functional status, medications, and chief complaint
Adaptable to background noise, multilingual interactions, advanced versions discern discussions of pertinent health information
May improve clinical efficiency
Decrease administrative burden
Reduce documentation outside of work (Subjective portion can be lengthy!!)
Allows more face-to-face interaction
Benefits of AI Technology for Subjective Documentation
Patient reports decreased pain when performing exercises at home
response to treatment interventions
the 3 purposes for the review of systems
Helps the PT to determine if a patient is suitable to receive physical therapy
Identify medical conditions that may impact the patient's ability to performexercises in PT
Determine if patient should be referred to a different healthcare professional
Valid and reliable documentation of tests and measures can be used for diagnosis and prognosis
Clearly evaluate and communicate changes to patient functioning
Plan of care based on research and clinical guidelines reflective of patient preferences
What do these help demonstrate?
APTA Defensible Documentation shows documentation can help demonstrate evidence-based practice
3 times when quoting the patient verbatim is appropriate
1. confusion or memory loss
2. denial
3. describe pain