Documentation & Reporting

ICF terms

-body functions: function of body system -bosy structures: anatomical part -impairments: problems with body function and structures -environmental factors: physical, social, attitudinal environment that people live, facilitators or barriers -activity -participation -activity limits -participation restrictions -functioning: positive or neutral aspects of the interaction between persons health condition and contextual factors -disability: impairments, activity limits, participation restrictions, negative aspects of persons health condition and contextual factors

disability in medical models

-characteristic or attribute of the person -directly caused by disease, trauma, health condition -required intervention to correct or compensate for problem

skilled intervention

-documents critical and clinical decision making -why intervention selected -assessments to gauge changes in status with intervention -connects intervention to impairment, activity limit, participation restriction -NOT repetitive intervention or exercise of general health and wellness

using ICF in PT ex 1

-health condition: spinal injury -impairment: paralysis -activity limit: cannot use public transport -participation restrict: lack of accommodation in public transportation leads to no participation in religious activities

using ICF in PT ex 2

-health: cerebral palsy -impairment: joint function, contractures -activity limit: hard to walk -participation restrict: restricted education, community life -need for skilled care and prognosis-->expected outcome AND timeline

disability in biopsychosocial models

-integrates medical and social models -disability is viewed as consequence of biological, personal, social forces

What to document

-is PT medically necessary -are the injuries of the pt such that your skilled intervention is needed

goal writing

-measurable -pt specific: pertain to identified functional impairments: PLOF vs CLOF -objective findings

Pay complaints about documentation

-poor legibility -incomplete documentation -abbreviations -doc does not support billing -doesnt demonstrate skilled care -doesnt support medical necessity -doesnt show progress -repeats daily notes

aim of ICF

-provide scientific basis for understanding and studying health, outcomes, determinants, changes in health status and functioning -establish common language for describing health states -permit comparison of data across countries, disciplines, services, and times -provide systematic coding scheme for health info systems

disability in social models

-socially created problem -underlying problem is created by inflexible environment -solution calls for political response or solution

needs to show medical necessity

-what are the complications and safety issues as a result of pt current status -ex: mod A, pt remains at risk for falling -unable to perform bed mobility without intervention, remains at risk for complications of skin breakdown -unable to perform ADLs

documenting assessment

-what did you notice/do about required skill: pt demonstrates use of arm strategy and valgus knee collapse with lateral step down -why is it important: given VC and TC to increase safety -what do they need that is skilled: pt would benefit from further coordination test and cueing to improve and decrease load -plan: improve ABD strength and decrease step height

documenting skilled intervention

-what was done in visit that required the skill of a PT -why did you have to provide intervention rather than family member -what knowledge, training, skill was used -pt required TC, VC, mod A, pt education, ambulation training, monitor vital signs, demonstrates good balance--> intervention progressed

APTA ICF

ICF provides framework for PT practice to prevent, minimize, or eliminate impairments of body functions and structures, activity limits, and participation restrictions by optimizing movement