Documentation

Waleed Al-Shehri ,BSc.PTKing Saud university

College of applied Medical Science Rehabilitation Science Department

Physical Therapy

Why?

• For communication with other health team.• Legal document.• Used in the patient's record for review and

quality control.• Continuing Evaluation.• Researches.

POMR

POMR

• Problem Oriented Medical Record.• Weed & Zimny.• Four Phases.

Treatment Process

Database POC Patient ProgressImpairments

SOAP Note

SOAP Note

Initial Evaluation Progress Notes Discharge Summary

Initial Assessment

Subjective

• General Data. • Description of Problem.• History of Present Problem.• Past Medical History.• Psycho-Social History.

Objective

• Observation.• Physical.• Cognitive.• Behavior.• Measurable Terms.

Assessment

Assessment

Problem List Short-term Goals Long Term GoalsImpressionsor Summary

Problem List

1. Review the S and 0 portions of the note, jotting down or highlighting findings that are not WNL and that can be influenced or changed by rehabilitation.(Medical or psychiatric problems do not belong in the rehabilitation problem list.)

2. Set priorities as to which problem is the most important, the next important, and so forth.

3. List the problems to be addressed during rehabilitation in order of priority.

Short-term Goals

1. Are the steps along the way to achieving long-term goals.

2. Are based on the long-term goals.

3. Serve as the basis for treatment planning.

4. Components of short-term goals are the same as those of long-term goals.

Long Term Goals

1. State the long-term outcomes of rehabilitation.

2. Are based on the problem list.

3. Are the bases for setting short-term goals.

Reliable

Specific Measurable

Timed

Achievable

Goal

Impressions or Summary

Can include any of the following types of information:

a. Correlations between the subjective and objective information in the note.

b. Justification for the goals and/or treatment plan.

c. Clarification of the patient major problems.

d. Justification for further treatment.

Impressions or Summary

e. A discussion of the patient progress (or lack of progress) in rehabilitation.

f. A discussion of the patient rehabilitation potential and why.

g. An explanation of any difficulties in obtaining information during the initial assessment and testing.

h. Suggestions for further testing/treatment needed.

Plan

must include the following information:

A. Frequency per day or per week that the athlete will be seen.

B. Treatment the patient will receive.

C. Location of the treatment.

D. The treatment progression.

E. Plans for further assessment or reassessment.

Plan

F. Plans for discharge.

G. Athlete and family education.

H. Equipment needs and equipment ordered for/sold to the patient.

I. Referral to other services; if there are plans to consult with the patient’s physician regarding further treatment or referral.

Progress Notes

Progress Notes

S (Subjective):Includes updates or additional information.

O (Objective):Update or add to the information reported in the initial note or last

interim note.

A (Assessment):Refers to the short-term goal(s) achieved and new short-term goal(s)

set. If a short-term goal has not yet been achieved, the notes tell the reason why the goal has not been achieved.

P (Plan):The treatment plan will need to be revised as the patient's condition is

reassessed and new short-term goals are set.

Discharge Summary

Discharge Summary

S (Subjective):Completely summarizes the patient’s complaints, home

situation, whether the patient feels the goals set were achieved or not.

O (Objective):Completely summarizes the patient’s condition upon

discharge from the facility (more similar to the initial note in format and length).

A (Assessment):comments are made on the most recently set short-term

goals and why they were or were not achieved.

P (Plan):1. Overview of treatment.

2. Home program instructions given.

3. Other types of instructions given.

4. Any type of equipment sold to the patient.

5. Referral to a home health agency or any other professional.

6. The number of times the patient was seen.

Discharge Summary

7. If and when the patient was not seen, on hold and why.

8. Any instances of the patient skipping or canceling treatment sessions.

9. To where the patient is discharged.

10. The reason for discharge.

11. Recommendations for follow up treatment or care given to the patient.

Discharge Summary

Don’t Forget!

• Every session.• Don’t Use abbreviations.• The language should be easily understood by all.• Writing the SOAP immediately after The session.• Signature.• Errors must be crossed through with a single line.

Thank You