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    Physiotherapy Documentation..example

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    vingkadwiini
    The document discusses physical therapy documentation and treatment. It provides details on the components of documentation including patient information, medical diagnosis, treatment history, and the five elements of patient management in physical therapy - examination, evaluation, diagnosis, prognosis, and intervention. Guidelines from the American Physical Therapy Association are outlined including documenting self-report, interventions, equipment, changes in status, complications, and factors changing intervention. Examples of common physical therapy types like orthopedic and neurological PT are briefly described. The importance of documentation for legal and reimbursement purposes is mentioned. Sample questions physiotherapists may ask patients are listed.

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    Physiotherapy Documentation..example

    Uploaded by

    vingkadwiini
    58 views11 pages
    The document discusses physical therapy documentation and treatment. It provides details on the components of documentation including patient information, medical diagnosis, treatment history, and the five elements of patient management in physical therapy - examination, evaluation, diagnosis, prognosis, and intervention. Guidelines from the American Physical Therapy Association are outlined including documenting self-report, interventions, equipment, changes in status, complications, and factors changing intervention. Examples of common physical therapy types like orthopedic and neurological PT are briefly described. The importance of documentation for legal and reimbursement purposes is mentioned. Sample questions physiotherapists may ask patients are listed.

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    PHYSIOTHERAPY DOCUMENTATION..EXAMPLE

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    The document discusses physical therapy documentation and treatment. It provides details on the components of documentation including patient information, medical diagnosis, treatment history, and the five elements of patient management in physical therapy - examination, evaluation, diagnosis, prognosis, and intervention. Guidelines from the American Physical Therapy Association are outlined including documenting self-report, interventions, equipment, changes in status, complications, and factors changing intervention. Examples of common physical therapy types like orthopedic and neurological PT are briefly described. The importance of documentation for legal and reimbursement purposes is mentioned. Sample questions physiotherapists may ask patients are listed.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    58 views11 pages

    Physiotherapy Documentation..example

    Uploaded by

    vingkadwiini
    The document discusses physical therapy documentation and treatment. It provides details on the components of documentation including patient information, medical diagnosis, treatment history, and the five elements of patient management in physical therapy - examination, evaluation, diagnosis, prognosis, and intervention. Guidelines from the American Physical Therapy Association are outlined including documenting self-report, interventions, equipment, changes in status, complications, and factors changing intervention. Examples of common physical therapy types like orthopedic and neurological PT are briefly described. The importance of documentation for legal and reimbursement purposes is mentioned. Sample questions physiotherapists may ask patients are listed.

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    of 11

    PHYSIOTHERAPY

    DOCUMENTATION
     Though your physical therapy documentation may expand as a
    patient continues along an episode of care, general components
    of quality physical therapy documentation examples
    include: Patient details (DOB, name, physician contact
    information) Medical diagnosis. Past medical and PT treatment
    history.
    The 5 elements in physical therapy

     The physical therapist integrates the five


    elements of patient/client management –
    examination, evaluation, diagnosis, prognosis,
    and intervention – in a manner designed to
    optimize outcomes
     Documentation of a visit, often called
    a daily note or treatment note, documents
    sequential implementation of the physical
    therapist plan of care.31 Jan 2018
     However, the American Physical Therapy Association does
    provide the following guidance on what information should be
    included:
    1. Self-report of the patient.
    2. Details of the specific intervention provided.
    3. Equipment used.
    4. Changes in patient status.
    5. Complications or adverse reactions.
    6. Factors that change the intervention
     Physical therapy, also known as physiotherapy,
    may include certain exercises, massages and
    treatments based on physical stimuli (e.g. heat,
    cold, electrical currents or ultrasound). The aim
    of physical therapy is to relieve pain, help you
    move better or strengthen weakened muscles.
    Why documentation is important for the
    physiotherapist ?
     Documentation is also done to provide legal evidence
    as to exactly what took place during each therapy
    session and also to communicate with other health
    professionals. Documentation serves another
    important purpose to JUSTIFY to the INSURERS that
    proper care was provided and DESERVES to be
    reimbursed.
    What is physiotherapist note ?

     Physiotherapy is treatment to restore, maintain,


    and make the most of a patient's mobility,
    function, and well-being. Physiotherapy helps
    through physical rehabilitation, injury
    prevention, and health and fitness.
    Physiotherapists get you involved in your own
    recovery.
     Here are some common types of PT:
    • Orthopedic PT: Orthopedic PT focuses on
    musculoskeletal injuries and conditions, such as
    fractures, sprains, and joint replacements.
    • Neurological PT: Neurological PT deals with neurological
    disorders like stroke, Parkinson's disease, spinal cord
    injuries, and multiple sclerosis
    EXAMPLE OF QUESTIONS TO PATIENTS :

     WHAT IS YOUR COMPLAIN ?


     WHERE IS THE PAIN ?
     IS IT PAIN HERE ?
     WHAT DO YOU FEEL WHEN I PRESS YOUR………………?
     HAVE YOU EVER GONE TO THE DOCTOR TO CONSULT YOUR PAIN ?
     WHEN IS IT ?
     HAVE YOU TAKEN THE MEDECINE BEFORE ?
     HOW MANY TIMES DO YOU TAKE THE MEDECINE IN A DAY ?
     DO YOU FEEL THERE IS ANY PROGRESS AFTER TAKING THE MEDECINE ?
     WHAT DO YOU FEEL WHEN I PUT ON THIS ULTRASOUND ?
     IS THE HEAT ENOUGH FOR YOU ? ( IS IT TOO HOT FOR YOU ?)
     DO YOU THINK THAT I NEED TO INCREASE THE HEAT ?
     WHAT DO YOU FEEL WHEN I BEND YOUR KNEES ?
     IS IT PAIN WHEN I TOUCH YOUR NECK ?
     HAVE YOU DONE THE EXERCISE AT HOME ?
     DO YOU DO THE EXERCISE THAT I TOLD YOU BEFORE ?
     HOW MANY MINUTES DO YOU TAKE YOUR TIME FOR THE EXERCISES ?
     IS THERE ANY PROGRESS ON YOUR …… AFTER DOING EXERCISES ?

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