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Understanding Disability Models and Physical Therapy Documentation Study Guide

This guide covers theoretical models of disability, the distinction between medical and physical therapy diagnoses, and the structured components of the initial examination and evaluation process in physical therapy. It details the Nagi Model and the ICF Model, explains the diagnostic process, outlines the components of the initial examination and evaluation including subjective and objective data collection, and discusses documentation formats and best practices like the SOAP note.

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Principles and Components of Physical Therapy Documentation

Documenting Subjective Patient Information

State information from patient that is relevant to the patient's present condition using specific reports.

  • patient reports
  • pain quantification
  • symptom reduction
  • muscle soreness
  • subjective information

Clinical Documentation and SOAP Note Components

Guidelines for writing subjective and objective notes including diagnosis statements, therapeutic communication, and measurable objective data.

  • SOAP Note
  • Subjective documentation
  • Objective documentation
  • Diagnosis statements
  • ICF model
  • Therapeutic communication
  • Open-ended questions
  • Closed questions
  • Patient/Family Goals
  • Prior level of function
  • Measurable and reproducible testing procedures

Clinical Documentation and Physical Therapy Interventions

Guidelines for recording treatment interventions, patient observations, levels of assistance, and functional descriptions in clinical documentation.

  • Treatment interventions
  • Mobility training
  • Therapeutic exercises
  • Modalities
  • Neuromuscular re-education
  • Patient level of alertness
  • Physical therapy observations
  • Levels of assistance
  • Verbal cueing
  • Family and caregiver training

Purposes of Physical Therapy Documentation

Physical therapy documentation serves as legal proof of medical care, facilitates communication with healthcare professionals, and provides the basis for appropriate reimbursement for skilled patient care.

  • Purposes of documentation
  • Legal proof of medical care
  • Organization of thoughts during patient care
  • Communication with healthcare professionals
  • Replication of care in the treatment process
  • Quality of patient care
  • Evidence Based Practice
  • Reimbursement for skilled patient care
  • Compliance with federal laws and regulations

Models of Disability and PT Documentation

This content covers models of disability, the physical therapy diagnosis process, and components of the initial examination and evaluation.

  • Nagi Model
  • International Classification of Functioning, Disability and Health Model (ICF)
  • PT Diagnosis
  • Medical Diagnosis
  • Subjective Information
  • Objective Data
  • Standardized Tests and Measures
  • Short Term Goals (STGs)
  • Long Term Goals (LTGs)
  • Treatment Plan (Plan of Care)
  • Prognosis
  • Documentation Formats

Clinical Documentation and Medical Terminology

24 Hour Military Clock Conversions

A comparison between regular time and military time including midnight, noon, and hourly increments.

  • 24 hour military clock
  • Regular Time
  • Military Time

Medical and Rehabilitation Abbreviation List

A comprehensive list of medical abbreviations including anatomical terms, clinical diagnoses, and rehabilitation terminology.

  • anatomical terms
  • clinical diagnoses
  • rehabilitation terminology
  • medical abbreviations
  • measurement units

Medical and Physical Therapy Abbreviations

A list of medical abbreviations including clinical terms, anatomical references, and treatment protocols.

  • medical abbreviations
  • physical therapy terminology
  • anatomical abbreviations
  • clinical assessment terms
  • treatment and exercise abbreviations

Subjective and Objective Patient Care Practice

Determine appropriate information for Subjective and Objective parts of notes by watching actual patient care videos.

  • Subjective and Objective parts of notes
  • Total Hip Replacement initial assessment
  • Bedside exercises
  • Preparing to stand
  • Ambulation in acute care

Clinical Documentation for Physical Therapist Assistants

This lecture covers PTA documentation responsibilities, legal requirements, HIPAA, and the organization of subjective and objective data.

  • Purpose of Documentation
  • PTA Responsibilities
  • HIPAA
  • Nagi Model
  • International Classification of Functioning, Disability, and Health Model
  • Subjective Information
  • Objective Data
  • SOAP Note
  • Person-first Language
  • Medical Record Accuracy

Medical Record Documentation and SOAP Notes

Guidelines for writing in a medical record using the SOAP note model and person first language.

  • SOAP note
  • Subjective
  • Objective
  • Assessment
  • Plan
  • Accuracy
  • Brevity
  • Clarity
  • Timeliness
  • Person first language
  • Medical record documentation rules

Example of Flow Sheets Exercises

Example of flow sheets including outer hip strengthening, inside calf strengthening, outside calf strengthening, towel crunch, step up, step down, stretching exercises, quad stretch, calf stretch, ham stretch, knee cap stretch, strengthening exercises, towel squeeze, VMO strengthening, one quarter squat, and single leg one quarter squat.

  • Outer Hip Strengthening
  • Inside Calf Strengthening
  • Outside Calf Strengthening
  • Step Up
  • Step Down
  • Stretching Exercises
  • Quad Stretch
  • Calf Stretch
  • Ham Stretch
  • Knee Cap Stretch
  • Strengthening Exercises
  • Towel Squeeze
  • VMO Strengthening
  • One Quarter Squat
  • Single Leg One Quarter Squat

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