HSC 1531 Project Treatment Notes

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HSC 1531 Project Treatment Notes

HSC 1531 Project Treatment Notes

In this
course project assignment, you are presented with treatment notes for two
different patients. Treatment Notes often include medication orders, medication
administration, and documentation of procedures, such as physical therapy,
respiratory therapy, nutrition counseling, and radiation therapy. These notes
include details regarding the type, length, and necessity of treatment. Treatment
notes are important to track the execution of the patient’s treatment plan and
monitor progression of his or her health outcomes.

You will be
exploring the medical terminology used in these test results and will be asked
to interpret the meanings of various words and abbreviations.

To complete
this assignment, do the following:

Download
the treatment notes for the two patients:

Michelle
Gibbler Treatment Notes

Todd
Anderson Treatment Notes

Download,
complete, and submit the document below. This document contains questions you
will answer regarding the treatment notes for each patient.

Module 05
Course Project Assignment Template

Submit your
completed assignment by following the directions linked below. Please check the
Course Calendar for specific due dates.

Save your
assignment as a Microsoft Word document. (Mac users, please remember to append
the “.docx” extension to the filename.) The name of the file should
be your first initial and last name, followed by an underscore and the name of
the assignment, and an underscore and the date. An example is shown below:

 

Treatment Notes and Progress Notes Using a Modified SOAP Format

LEARNING OBJECTIVES

After reading this chapter and completing the exercises, the reader will be able to:

1. Identify and describe the key components of a treatment note.

2. Identify and describe the key components of a progress note.

3. Appropriately document components of treatment notes and progress notes using a modified SOAP format.

Treatment notes and progress notes are a key component of physical therapy documentation. In fact, many therapists spend a majority of their documentation time writing these types of notes. Although the focus of this book thus far has been on documenting the initial evaluation, all elements included in treatment or progress notes are essentially components of the initial evaluation. The concepts discussed in the previous chapters all apply here.

Although there are no formal guidelines from either APTA or CMS regarding the structure of treatment or progress notes, such documentation can become unwieldy without some organization. The SOAP note is a commonly used format and is one with which most medical personnel are familiar (see Chapter 2 for the history and development of the SOAP note). The SOAP format is relatively easy to master and provides a quick format for writing a treatment note. This chapter presents a format for writing both treatment notes and progress notes using a modified SOAP format.

Modified SOAP Format

The acronym SOAP stands for subjective, objective, assessment, and plan. This format was discussed briefly in Chapter 2 and is presented here as a framework for treatment and progress note documentation. However, the original design for use of the SOAP note is not how it is currently used by most medical professionals. The SOAP note was designed to promote a sequential rather than an integrative approach to clinical decision making and was linked to the problem-oriented medical record, which is no longer routinely used. However, with some modifications the SOAP note can provide the foundation for efficient, effective functional outcomes documentation in rehabilitation.

The figures and tables in this chapter outline key components of these notes to meet criteria necessary for optimal clinical decision making, third-party payment, and legal purposes. Because treatment notes must serve such diverse purposes, there may be a tendency for therapists to write excessively long notes. Strategies for simplifying documentation are provided in Box 12-1. Furthermore, the case examples at the end of the chapter demonstrate how such notes are modified for different patients in different practice settings.

BOX 12-1   Time-Saving Tips for Writing Session Notes

• Keep printout of patient’s goals readily visible in the front of the patient’s chart.

• Use tables and flowcharts whenever possible (Case Example 12-5) for documenting both interventions and outcomes.

• When documenting tests and measures, focus on changes to patient’s status.

• Use electronic documentation whenever possible. Even if your facility has not yet implemented a complete system, use a word processor and write your own documentation template.

Treatment Notes

Treatment notes are written for each encounter a PT or PTA has with a patient (Case Examples 12-1, 12-2, and 12-3). Although APTA documentation guidelines and most third-party payers require documentation for each physical therapy encounter, the format of treatment note documentation is at the discretion of each institution.

CASE EXAMPLE 12-1   Treatment Note

Setting: Outpatient

Name: Emily Rodriguez  D.O.B.: 2/3/77  Date of Eval.: 1/5/09

CURRENT CONDITION

31 y.o. female 12 wk postpartum image onset of stress incontinence p vaginal delivery of first child.

Goal: Decrease urine losses from 2× daily to 1×/wk.

S: Pt. reports urinary losses of 1 tablespoon have decreased to 1×/day over past 3 days. Occurs primarily when coughing or during physical activities, such as lifting baskets of laundry, running, and jumping. Pt. continues to wear 2 panty-liners daily as continued precaution to protect clothing.

OStatus update: Biofeedback reassessment was completed in supine with noted improvement in EMG activity levels for pelvic muscle contractions. Fair strength of pelvic floor muscle contraction, held 5 sec ×7 reps.

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Rx: Pt. performed pelvic floor muscle contractions image biofeedback program in the standing position. Pt. performed pelvic floor muscle contractions during a lunge to floor and back to standing, 3 reps each LE (practicing the movement for lifting a laundry basket). Practiced pelvic muscle contractions prior to a cough, 5 reps. Pt. ed: pelvic muscle contraction before cough or lifting heavy objects to prevent incontinence. Revised HEP to ↑ pelvic muscle contractions in sitting for 20 1-sec contractions; followed by 20 min of 10-sec contractions in sitting.

A: Pt. reports decrease in urinary losses over past 3 days, which correlates with observed improvements in EMG activity levels for pelvic floor muscle contractions.

P: Continue PT 1×/wk. Progress with pelvic muscle strength trng and muscle reeducation during functional tasks, with instruction in progressive HEP to improve pt.’s level of ADLs.

CASE EXAMPLE 12-2   Treatment Note

Setting: Inpatient

Name: Wally Narcessian  D.O.B.: 3/7/37  Date of Eval.: 6/20/09 (10:26:00 AM)

CURRENT CONDITION

COPD/pneumonia

Goals

1. Pt. will demonstrate productive cough in a seated position, 3/4 trials.

2. Pt. will ambulate 150 ft with supervision, no A device, on level indoor surfaces, within 45 sec (to enable in-home ambulation).

S: Pt. reports not feeling well today, “I’m very tired.”

OStatus update: Auscultation findings: scattered rhonchi all lung fields.

Rx: Chest PT was performed in sitting (ant and post). Techniques included percussion, vibration, and shaking. Pt. performed a weak combined abdominal and upper costal cough that was nonbronchospastic, congested, and nonproductive. The cough/huff was performed with verbal cues. Pectoral stretch/thoracic cage mobilizations performed in seated position. Pt. given towel roll placed in back of seat to open up ant chest wall. Strengthening exercises in standing—pt. performed hip flexion, extension, and abduction; knee flexion 10 reps ×1 set B. Pt. performs HEP with supervision (in evenings with wife). Pt. instructed to hold tissue over trach when speaking to prevent infection and explained importance of drinking enough water.

A: Pt. continues to present with congestion and limitations in coughing productivity. Pt. has been compliant with evening exercise program, which has resulted in increased tol. to ther ex. regimen and an increase in LE strength. Amb. not attempted today 2 ° to pt. report of fatigue. Pt. should be able to tolerate short-distance amb. within next few days.

P: Cont. current treatment plan including CPT; emphasize productive coughing techniques; increase strengthening exer reps to 15; attempt amb. again tomorrow.

CASE EXAMPLE 12-3   Treatment Note

Setting: Outpatient

Name: Julie Jones  D.O.B.: 10/1/63  Date of Eval.: 6/20/09

CURRENT CONDITION

chronic left shoulder capsulitis

Goal

1. To return to playing tennis, pain-free in 4 wk.

S: Patient reports L shoulder pain localized over lateral brachial region when serving during a tennis game.

OStatus update: Patient performs tennis “serving” techniques with tennis racket on the tennis courts outside the PT gym, and reports being able to successfully complete 7 serves before the onset of pain. Rx: US to L inferior anterior shoulder, 1 MHz/1.0  W/cm2, continuous for 5 min with patient in supine and L UE supported with pillows in abduction and external rotation. Followed by shoulder joint mob, inferior glide grade 4. Strengthening exercises with yellow Theraband for int. rotation, ext. rotation, flex and ext of L shoulder. Pt. education: practice tennis serves and review proper motion and technique.

A: Patient has been making slow gains in reducing L shoulder pain during her recreational activities of tennis. She has been able to increase the time of her tennis games from 20 min to 40 min as she is able to manage her pain more effectively.

P: Continue image US, joint mobs, and stretching to increase shoulder abduction. Pt. will be given HEP to increase ROM and function of L UE next session.

Treatment notes are written for four distinct reasons:

1. Legal documentation. A treatment note importantly provides a legal record of what was done in a therapy session and why. For this reason, documentation of the specifics of the interventions performed and the patient’s reaction to those interventions is critical.

2. Third-party payment. Third-party payers typically request that treatment notes be provided as proof of service. Medicare, for example, requires documentation to create a record of all treatments and skilled interventions to justify the use of billing codes.

3. To facilitate functional outcomes and clinical decision making. Writing a treatment note that focuses on functional outcomes helps to maintain a therapist’s attention on patient-specific goals. Each treatment note allows the therapist the time to reevaluate the patient’s progress and goals and to consider changes to the plan of care.

4. As a record for other therapists in case of absence. In the event that a therapist is absent, it is important for any covering therapist to have a complete record of the specific interventions that were performed with a patient.

FRAMEWORK FOR TREATMENT NOTE DOCUMENTATION

The framework for treatment note documentation includes goals (G), subjective (S), objective (O), assessment (A), and plan (P) (Figure 12-1).

image
FIGURE 12-1 Framework for treatment note documentation using a modified SOAP format. Recommendations from APTA Documentation (Appendix A) and current CMS requirements for treatment note documentation are incorporated into this framework.

Goals

From a functional outcomes perspective, the focus of treatment notes should be on the specific goals that are being addressed. Thus the goals should be readily visible to the therapist as he or she writes the treatment note. This can be accomplished by adding a statement at the beginning of the SOAP note that identifies the goals, possibly including only those that were the focus of that treatment (restatement of the goals that were set at the time of the intial evaluation or last progress note). Alternatively, therapists can easily have the patient’s goals reproduced at the beginning of the SOAP note. This can be more easily accomplished using computerized documentation.

Common Pitfall

Goals are not included. Restating the goal(s) forces the therapist to maintain a focus on the outcomes toward which therapeutic intervention is directed.

Subjective (S)

In the Subjective section of the treatment note, the therapist documents the patient’s subjective respon-ses to interventions and any changes in participation or activity limitations. This section could include any relevant statements or reports made by the patient, patient’s family members, and/or caregivers. The purpose of this section is to detail the patient’s own perception of his or her condition, which can relate to impairments (e.g., pain), activities (e.g., ability to walk), or participation (e.g., ability to work). Box 12-2 provides more information on documenting pain in treatment notes.

BOX 12-2   Documenting Pain in Treatment Notes and Progress Notes

In the initial evaluation, a detailed description of pain is recommended, including location, quality, severity, timing, and factors that make it better or worse (see Box 8-1). The setting in which pain occurs and any associated manifestations may also be included.

In the session note or progress note documentation, a change in any component of pain is worthy of documentation. Decrease in pain severity (e.g., “Pt. reports pain has decreased to 2/10”) or quality (e.g., “Pt reports pain has gone from a burning, stabbing pain to an aching pain”) can be indicators of patient improvement. It is not essential in the treatment note or progress note to completely redocument the detailed pain assessment provided in an initial note. Rather, changes in the patient’s report of pain should be specifically documented.

Reports of pain (because they are inherently subjective) should typically be documented in the subjective section of a treatment note or a progress note. However, if report of pain is incidental to an objective statement, then it can be included in the objective section, e.g., “Pt. performed 10 reps ×3 sets SLR with no increase in pain.” This statement’s focus is on the intervention being performed.

This section of the note does not include direct observations made by the therapist. Therapists can report a patient’s or caregiver’s remarks in quotation marks if the exact phrasing is somehow pertinent. Documentation of subjective information should incorporate information that is relevant to the patient’s progress in rehabilitation and specifically related to changes in functional performance or quality of life. It should not include extraneous information that is not directly related to the patient’s current condition.

Common Pitfall

Documentation is not specific enough (e.g., Pt. reports pain is getting better). Such a statement needs to be more specific:

Pt. reports pain in left hip during walking has improved from 6/10 to 4/10.

The therapist could also document nonpatient information. For example, a therapist might write Pt. reports she didn’t like her last PT. This statement is not pertinent.

Pt. reports she was “unsatisfied with her previous treatment results” and is hoping for more significant improvement in her walking ability.

This statement is more specific to the patient’s concern.

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