PTA 100 final

Purposes of Documentation

"If it isn't documented, it didn't happen" Serves as a record of what occurred in a given intervention session Professional responsibility - standard of care American Physical Therapy Association (APTA)

The Rights of the Patient

"Paternalism" meaning the patient expects the healthcare provider to make all of the decisions versus "shared decision making"

What is Critical Appraisal?

"The assessment of evidence by systematically reviewing the relevance, validity and results to specific situations" NOT Negative dismissal of a piece of research Assessment of results alone Based entirely on detailed statistical analysis Utilized only by expert researchers

APTA Vision Statement for Physical Therapy

"Transforming Society by Optimizing Movement to Improve the Human Experience" How will your work as a PTA transform society?

A I D E T

A = Acknowledge I = Introduce D = Give Duration E = Explain What You Are Going To Do T = THANK YOU

Parameters for Communication with Others

A PTA should be able to Answer questions regarding the rationale for performing an exercise or technique or using a physical agent Share knowledge regarding a patient diagnosis Discuss relevant factual information from clinical experience Resolving conflict Often related to differences in expectations Not necessary to "place blame" Bring in third party only if issue can't be resolved within team Working with multiple therapists PTA needs to adapt style Identify supervising PT and/or "PT of record"

Cultural Competence - Definition

A set of congruent behaviors, practices, attitudes and policies that come together in a system or agency or among professionals, enabling effective work to be done in cross-cultural situations

Ethical dilemma

A situation in which two courses of action can be equally appropriate What is considered unethical in one culture may not be considered unethical in another. Something unethical is not always illegal, but something illegal is almost always unethical

APTA's Role in Defining the Future of the PTA

APTA currently has the position that the AAS degree is the appropriate entry - level degree for the PTA Recognition of Advanced Proficiency for the Physical Therapist Assistant Current events APTA's Healthcare Professionals and Personnel Involved in the Delivery of Physical Therapy Task Force Investigating potential changes to current utilization of support personnel

Reading a Research Article

Abstract Beginning of article Brief description of purpose, methods, outcomes, and importance of study Introduction Background on why research was necessary Literature review (previous studies on topic) Purpose of study Hypothesis Prediction of outcome How variables are connected Example = Null hypothesis which predicts no difference between variables

KEYS to GOOD MEDICAL DOCUMENTATION

Accuracy: NEVER embellish the truth or lie Brevity: notes should be concise NO: Pt. reports pain in LLE. Pt. reports this is limiting his ROM. Pt. reports he can't walk with pain. YES: Pt. reports pain in LLE limiting ROM. Can't amb with pain. Clarity: the meaning should be immediately clear to the reader Pt. vs PT statements You should document what the patient does, not what you did to the patient. NO: I assisted the patient to amb. 35ft from w/c to toilet YES: Pt. amb 35ft w/c to toilet c min A

Definition of Function

Activity: the execution of a task or action by an individual Participation: involvement in a life situation Activity Limitations: difficulties and individual may have in executing activities Participation Restrictions: problems an individual may experience in involvement in life situations Environmental Factors :make up the physical, social and attitudinal environment in which people live and conduct their lives.

ESSENTIALS OF COMMUNICATIONDos

Always think ahead about what you are going to say. Use simple words and phrases that are understood by every body. Increase your knowledge on all subjects you are required to speak. Speak clearly and audibly. Check twice with the listener whether you have been understood accurately or not In case of an interruption, always do a little recap of what has been already said. Always pay undivided attention to the speaker while listening. While listening, always make notes of important points. Always ask for clarification if you have failed to grasp other's point of view. Repeat what the speaker has said to check whether you have understood accurately.

BASIC REQUIREMENTS SOAP

Always use blue or black ink; never document in pencil Make sure the note is legible to ensure the information is read correctly Begin your documentation on the first available line at the top If you do not completely fill a space, draw a single line through the space so other information cannot be added Documentation should proceed sequentially in date order If you need to add information at a later date, write the following at the beginning of your entry: "addendum to physical therapy noted dated ______" Always sign your name and place your title after each entry All notes by a student must be signed by the supervising PT or PTA Some facilities or insurance providers require the PT to sign all notes by the PTA (MAKE SURE THIS IS EQUITABLE WITH STATE LAWS) At least one place on the form should have your printed name If you make a mistake, draw a single line through the mistake, write "error" and initial. Do not ever scribble out or use white out error DM Pt. amb 150ft 200ft I with RW Use abbreviations sparingly as there is no guarantee they will be familiar to all readers If you must note something said / done by the therapist, it should be in 3rd person A reader with similar training should be able to review your notes and provide the same services

PATIENT RIGHTS

Amend their Records Request for Accounting of Disclosures Restricted Disclosure Request for Alternative Communication Complaint

The PTA'S Role in EBP

As part of their problem-solving capability, entry-level PTAs are expected to be able to: Read and understand a research article Identify the various sections of the article Describe the type of content to be found in each section Synthesize the relevant information as it applies to their clinical work Discuss evidence for and demonstrate understanding of why one intervention might be used rather than another This allows a PTA to provide better feedback to a PT, participate in discussion of pros/cons of alternative interventions, and help a PT in forming research questions.

Culture

Beliefs, values, and norms that people use to identify who they are and how they interact with others An individualized "lens" through which people view themselves, each other, and society The way we "do" things May be shaped by genetics, but more so by upbringing and experiences

ICF DOMAINS

Body Function and Structures Activities Participation

Components of the Preferred PT/PTA Relationship

Both the PT and PTA must develop Familiarity with the other's role Understanding of the similarities/differences in the roles Awareness and trust of each other's skills and knowledge base Strategies for effective communication

REGULATORY ORGANIZATIONS FOR HEALTH CARE

CDC - Center for Disease Control: monitors and strives to control infectious diseases TJC (formally JCAHO) - The Joint Commission: accreditor for hospitals to assure quality CORF - Comprehensive Outpatient Rehabilitation Facility typically regulated by Medicare and TJC Medicare - Federal Gov Insurance that covers elderly and disabled. They have a large number of regulations. Medicaid - Federal Gov mandated - State run insurance for disabled. They have a large number of regulations. Commercial / Workers Compensation / Tricare Insurance carriers have a large number of regulations. State Physical Therapy Practice Acts Agency for Healthcare Research and Quality (AHRQ) is another agency that falls under the U.S. Department of Health & Human Services (HHS). It conducts research aimed at improving the quality of health care, reducing costs and addressing patient safety and medical errors. National Committee for Quality Assurance (NCQA) ensures the quality of managed care plans. It was established in 1991 to provide standard and objective information about HMOs. Food and Drug Administration (FDA) is the federal regulatory agency responsible for controlling the safety and effectiveness of the country's drug supply for both humans and animals. The FDA regulates food safety, cosmetics, feed supply for animals, dietary supplements and biologics as well as the national blood supply, medical devices, food additives, product recalls and restaurant inspections. United States Agency for Toxic Substances and Disease Registry (ATSDR) monitors and regulates the effects of hazardous materials on public health. The ATSDR responds to hazardous material threats, educates the public on HAZMAT risks and encourages community members and organizations participation. Environmental Protection Agency (EPA), another federal agency, was created to protect human health and the environment through the writing and enforcing of regulations

What is Communication?

COMMUNICATION IS THE ART OF TRANSMITTING INFORMATION, IDEAS AND ATTITUDES FROM ONE PERSON TO ANOTHER. COMMUNICATION IS THE PROCESS OF MEANINGFUL INTERACTION AMONG HUMAN BEINGS. PERSONAL PROCESS OCCURS BETWEEN PEOPLE INVOLVES CHANGE IN BEHAVIOR MEANS TO INFLUENCE OTHERS EXPRESSION OF THOUGHTS AND EMOTIONS THROUGH WORDS & ACTIONS. TOOLS FOR CONTROLLING AND MOTIVATING PEOPLE. IT IS A SOCIAL AND EMOTIONAL PROCESS.

Ethnicity

Classification of people based on national origin or culture Examples: African American Asian American European American Hispanic American Middle Eastern Arabic American Native American

Characteristics of P&P Manual

Clear, concise, and easy to read Comprehensive Enforceable and consistent Accessible and up to date Positive

EBP GUIDE FOR CLINICAL DECISIONS

Clinical research data clinical experience pathophysiology of pt condition pt. values & preferences what is available in clinical practice setting

Evolution of Ethical Behaviorsin Physical Therapy

Code of Ethics 1935 Standards of Ethical Conduct for the Physical Therapist Assistant 1981 Both revised most recently in 2009

Systematic review Meta-analysis

Combination of results of several Randomized Controlled Trials Meta-analysis includes a statistical combination of the results Highest-level evidence if conducted properly Relies on enough Randomized Controlled Trials being available

Developing PTA Leadership Skills

Commitment to learning Interpersonal skills Communication skills Effective use of time and resources Use of constructive feedback Problem solving Professionalism Responsibility Critical thinking Stress management IN THE COMMUNITY PT and non-PT-related activities

Lifelong Learning Opportunities

Continuing education (CE) Participation in educational opportunities reflects a commitment to lifelong learning. Individual states may or may not have specific CE requirements for re-licensure or recertification. May need to be sponsored by specific types of organizations (APTA, academic institutions, etc.)

How do we Practice EBP?STEP 1

Convert the need for information into an answerable question. PICO format Patient or Problem Intervention or exposure Comparison, if any Outcome

TYPES OF LAWS

Criminal Offenses against society Established by state or federal legislation Civil Private offenses, one individual against another Common law: established by court decisions Tort law: often related to health-care common laws Administrative Regulations that involve government agencies State medical or PT board, practice act violations Medicare legislation, health department regulations

HHS REGULATIONS ON PRIVACY

DISCLOSURE Permits individuals to inspect and copy records about themselves. Enforce the rule of minimum necessary disclosure that is restrict disclosure to the minimum amount of information necessary to accomplish the purpose of use or disclosure.

Where did the ICF come from?

Developed by the World Health Organization (WHO) Large international and multidisciplinary participation Extensive field testing

Cultural Diversity

Differences based on cultural, ethnic, and racial factors "Melting Pot" or "Salad Bowl" approach Must be considered when providing health care Healthcare providers must recognize and appreciate the characteristics of all patients

How can a PT & PTA team learn each other's strengths?

Discussion times Share philosophies Co-treat Chart Reviews PTA sit in on initial evaluation

ESSENTIALS OF COMMUNICATION DON'Ts

Do not instantly react and mutter something in anger. Do not use technical terms & terminologies not understood by majority of people. Do not speak too fast or too slow. Do not speak in inaudible surroundings, as you won't be heard. Do not assume that every body understands you. While listening do not glance here and there as it might distract the speaker. Do not interrupt the speaker. Do not jump to the conclusion that you have understood every thing.

MEDICAL NECESSITY

Documented evidence of IMPAIRMENT - FUNCTION - DISABILITY Altered STRUCTURE with loss of FUNCTION Reasonable expectation of improvement in reasonable time-frame Documented significant improvements always related to FUNCTION SOONER than LATER (12-15 visits per episode of care)

BASICS OF ETHICS

ETHICS (dictionary definition) = "the study of the general nature of morals and of the specific moral choices to be made by the individual in his relationship with others" Your Text - philosophical reflection on questions of right or wrong

Legal Responsibility Within the PT/PTA Team

Each member has a responsibility "PT told me to do it' NEVER excuses the PTA PT retains ultimate responsibility

The Provider's Response to thePatient's Psychosocial Needs

Empathy (Davis) More than just being able to put themselves in their patients' situations Ability to perceive the patient's frame of reference Use that insight to connect more effectively with the patient Avoid sounding insincere Empowerment Enabling patients to take lead role in decision making Educating Encouraging involvement, giving choices Using "patient-first" language May be challenging to give up belief that "we know best" Advocacy The process of asserting oneself to represent the needs of a particular group or individual Accountability Doing what one says one will do Give examples of how these qualities might be demonstrated to patients

HISTORY

Enacted in 1996 by the federal government. (45 C.F.R. parts 160 & 164). Congress was to enact a confidentiality law by Aug 1999 but failed to do so. Health and Human Services (HHS) issued: Privacy regulations in April 2001 Security regulations in April 2003

Essential skills

Ethical decision making Critical thinking Communication

General guidelines

Every encounter / visit Comply with laws / payment regulations Identify patient / provider / date of service Authenticate all entries Identify referral mechanism (self-referral/direct access / from another provider (State of IL= MD, DO, Dentist, PA, APRN, DPM) Indicate no shows or cancellations

5 Elements of Patient/Client management

Examination Evaluation Diagnosis Prognosis intervention Intervention is the only component of patient/client management that can be performed by the PTA.

Nonverbal Elements of Communication

Facial expressions and body language Eye contact Personal space and touch Physical appearance of the provider Attitude and focus

The First Task: Passing the Licensure Examination

Federation State Board Physical Therapy (FSBPT) written examination = National Physical Therapy Exam (NPTE) Required in Illinois 200 multiple-choice questions, 150 of which are scored No penalty for guessing Jurisprudence examination - exam about Oral or written examination of state-specific laws Also not required in all states - Illinois does NOT require this

FUNCTION

Focus on how the patients FUNCTION is affected or impaired Document FUNCTION related to ADL's, Work, Recreation Utilize standardized tools Use APTA GUIDE to Physical Therapists Practice to determine functional diagnosis EXAMPLES OPTIMAL SF-36 Functional Independence Measure Berg Balance Score Orthopaedic Clinical Examination: An Evidence Based Approach for Physical Therapists (Netter Clinical Science) by Joshua Cleland DPT, PhD, OCS

Individuals with Disabilities Education Act (IDEA)

Formally called the Education for all Handicapped Children Act of 1975. Requires states to provide a free education for children with disabilities. Individualized Education Programs (IEP's) are developed for each child and reviewed

Laws Related to Abuse of Power

Fraud - knowingly misrepresenting the truth or concealing facts Abuse - unintentional misuse "Ignorance of law is no excuse" Failure to report suspected physical abuse What is the obligation of health-care providers in your state?

APTA Position: Levels of Supervision

General supervision Least restrictive PT is NOT required to be in same building Direct supervision PT must be on-site Daily interaction Direct personal supervision PT must be on-site and working directly with PTA tudents Must be direct supervision - PT must be on-site and working directly with PTA PTAs General supervision Least restrictive PT is NOT required to be in same building PTA aides Must be direct supervision - by a PTA or PT, however the PT must be on-site while the aide is working with the PTA

RED FLAGS

Generalized with no skilled explanation percentages increased - decreased min. - mod. - max. spasms / tightness antalgic gait PT provided only for pain Large gaps in treatment

American Physical Therapy Association (APTA) Viewpoints

Guidelines Are the least binding "Statement of advice" Positions "Firmly held association stance or point of view" Members are expected to follow Standards Have the highest level of expectation for compliance "Binding statement used to judge quality of action or activity" Often pertain to "right or wrong" conduct

INTERACTION OF CONCEPTS

HEALTH CONDITION BODY FUNCTION AND STRUCTURE (IMPAIRMENT) ACTIVITIES(LIMITATIONS) PARTICIPATION(RESTRICTION) ENVIRONMENTAL AND PERSONAL FACTORS

Documentation Principles

Handwritten or Electronic Style: concise / clear / complete / legible Abbreviations: different meanings / approved / used sparingly Errors: never erase - scribble over - white out / ----- error DM 11-15-15 Dates: every note / " late entry" Signatures: every note / regulatory title (PT or PTA) / students SPTA & countersigned by supervising PT or PTA Black ink: easier to visualize / photocopies better / NO PENCIL Third person: used sparingly / "this PTA" or "this clinician"

Hearing vs. Listening

Hearing - Physical process, natural, passive Listening - Physical as well as mental process, active, learned process, a skill

HUMAN FUNCTIONING

ICF does not measure disability It describes people's functional abilities in various domains Health conditions that affect functional status are not part of classification system Disability is not an "all or nothing" concept There is a wide range of functional limitations

NARRATIVE NOTE

If you are providing narrative documentation without using a specified format, it is important to include all necessary components The problem / diagnosis being addressed in PT A subjective report from patient A report of your findings from the session regarding objective data What does everything you've said so far mean with respect to the patient's functional abilities? What will happen next?

Randomized Controlled Trials

Includes treatment group and "control" group Random assignment to groups May involve "blinding" of participants and researchers Can be expensive and / or time consuming

SUBJECTIVE

Information relevant to the patient's care that he / she, significant others, or family members tell the PT or PTA. May include: Current symptoms Levels of pain Response to previous treatment Living situation Compliance with treatment Directly quote your patient's comments "my pain is a 10/ 10" Good terms to use in this section are expresses, describes, denies, states, reports, complains of When information is gained from someone other than the patient: The following information was gathered from Patty Parent, the patient's mother. " Kelly Kiddie is 18-months old and non-verbal." Information gained from both the patient and another individual: "Mr. Jones reports having difficulty walking up stairs because of his arthritis." "Mrs. Jones notes her husband has not been taking his arthritis medication since last week." pain scales and pain drawing

PT MEDICAL RECORD components

Initial Evaluation - PT ONLY History: Meds / Med history/ Surgical history / Prior functional level Systems Review: cardio / integument / muscle / neurological / cognitive / mental Test / Measures: physical measurements Evaluation: interpret data / integrate information Diagnosis: classification of problems as allowed by law / NOT a medical diagnosis Prognosis: predicted optimal level of improvement in function and the amount of time needed Plan of Care: the goals, predicted level of optimal improvement, specific interventions to be used, and proposed duration and frequency of the interventions that are required to reach the goals and outcomes.

Lifelong Learning Through Involvement in Research

Inservice Case study Poster presentation Platform presentation

MEDICAL NECESSITY CONT

Integrate evidence (research) into practice (Services are specific, safe, and effective according to accepted medical practice) Document skill - rationale - show knowledge (Services are consistent with nature and severity of illness, injury, medical needs) Outcomes that are functionally based Services do not just promote the general welfare of the patient/client. ENABLE the patient and then support and monitor Document interventions connected to the impairment and functional limitation. Document interventions connected to goals stated in plan of care. Identify who is providing care (PT, PTA, or both). Document complications of comorbidities, safety issues, etc.

ASSESSMENT

Interpretation of S and O sections for relevance "So what?" What you write in this section tells the reader why PT is necessary! Progress toward goals and outcomes Need for continued skilled services Reviewers must be able to see the reason for and results of skilled physical therapy services. What the PT includes: Problem list Clinical judgment including PT diagnosis Short term goals Long term goals What the PTA includes: Summary of what subjective & objective data for day "Means" Progress towards goals Completion of goals Recommended changes Need for re-evaluation by PT AVOID: saying "pt. tolerated treatment well" "pt. cooperative and motivated" Commenting on something not in the Objective or Subjective section - "came out if nowhere"

INTERPROFESSIONAL COLLABORATION

Interprofessional collaboration = a 'partnership between a team of health providers and a client in a participatory collaborative and coordinated approach to shared decision making around health and social issues. Open the following website and read the article. There will be 2-3 quiz and exam question related to this article. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3081249/

The Beginnings of the APTA

January 1921 - American Women's Physical Therapeutic Association 1946 - American Physical Therapy Association (APTA) Purpose of APTA Standardize education of PTs and PTAs Develop practice standards Promote the profession Research Legislation Advocate for patients and public

IMPROVING BODY LANGUAGE

Keep appropriate distance Touch only when appropriate Take care of your appearance Be aware - people may give false cues Maintain eye contact Smile genuinely

APTA "DEFENSIBLE DOCUMENTATION TOP TEN TIPS

Limit use of abbreviations. Date and sign all entries. Document legibly. Report functional progress towards goals regularly. Document at the time of the visit when possible.' Clearly identify note types, eg, progress reports, daily notes. Include all related communications. Include missed/cancelled visits. Demonstrate skilled care and medical necessity. Demonstrate discharge planning throughout the episode of care.

TYPES OF SYSTEMS

MEDICARE Government run - federal mandated - federally run & funded Covers the elderly and disable MEDICAID Government run - federal mandated - state run & funded Available for some, but not all of the poor State Children's Health Insurance Program covers children of low-income families. VETERANS HEALTH ADMINISTRATION Health care to U.S. military veterans through a nationwide network of government hospitals Federally funded and run TRICARE Active duty service members Retired service members and their eligible dependents are eligible for benefits through. Federally funded & run

Reading a Research Article (cont'd)

Methods Identifies the type of study performed (i.e: Random Controlled (RCT / Cohort / etc.) Defines if the researchers and/or the experiment group was blinded How people are placed in a group to assure randomization Describes what kind of study group was used: Experimental group = receives an intervention Control group = receives no intervention or a "sham" / "fake" intervention Comparison group = to look at effectiveness of one intervention compared to another Results Did the use of the independent variable (the intervention being studied) make a difference as measured by the dependent variable (the result of the intervention) Utilize statistics to verify this did not occur by chance Descriptive = summarize characteristics and distribution of data collected Parametric & nonparametric = math formulas that look at relationship and differences of data ** Key = understand what the stat is assessing ** Discussion Authors share why they obtained the results they did Clinical implications Comparison to previous studies (literature review) Includes a "limitation" section in which authors describe what they think created issues with the study and results Conclusion Summarizes the article Identifies need for future research

MULTIDSCIPLINARY

Minimum Data Set (MDS) - utilized in Skilled Nursing facilities Functional Independence Measure (FIM) - utilized by inpatient rehabilitation units Standardized Screens and Questionnaires - utilized by outpatient / inpatient/ rehab BERG OSWESTRY LOW BACK DASH

Example, continued

Mobility related activities, such as getting around the house or community can be improved with accessible environment and assistive devices Participation can be increased with reduced stigma, accessible environments and flexible job design Disability is NOT independent of the environment, and therefore is not static

Leadership Needs in Physical Therapy

Most important entry-level PTA traits (Clynch) Being able to recognize changes in the patient's status Appearing confident in one's own abilities Being able to manage time independently during patient interventions Being able to independently decide how to progress or modify delivery of a patient's intervention within the plan of care Being able to respond to variations in the daily schedule without demonstrating stress Strong oral and written communication skills Demonstrating a strong interest in learning and an ability to teach others Having a positive personality Being competent and knowledgeable Demonstrating high levels of responsibility

INFORMED CONSENT

Must be completed BEFORE episode of care begins. Includes: Explanation of findings of exam / eval Risks and benefits Opportunity for patient to ask questions Provision of choice Formal request and written permission to proceed

Steps in the Critical Appraisal

Need to know how the study is designed Need to know the strength of the design Need to assess reliability and validity (internal & external)

LEGAL TERMS

Negligence= failure to perform at a minimally acceptable level established to protect public Plantiff = alleged victim Proximate cause = legal cause Primary liability= taking responsibility for ones own actions Re ispa loquitor= "the thing speaks for itself"; lessens burden of proof in civil case Respondeat superior = "let the master answer" Slander= Defamatory comments about someone (spoken) Vicarious liability= responsibility for actions of someone under one's supervision (PTA)

Barriers to communication

Noise Inappropriate medium Assumptions/Misconceptions Emotions Language differences Poor listening skills Distractions

Ethics Terminology

Nonmaleficence - not doing harm Beneficence - doing good Justice - dealing with all people fairly Autonomy - the right to make individual choices Fidelity - keeping commitments made to others Veracity - being truthful in words and actions Duty - responsibilities owed to others

BASICS OF ETHICS

OVERT = open and observable, not concealed or hidden COVERT = hidden, concealed, destructive in nature All overt & covert acts are the product of irresponsibility LRH 1964

Why Be an APTA Member?

Only 7% of membership is licensed PTAs in US 5% of membership is PTA students!! What are the individual benefits of being an APTA member? Why do PTAs need to be active within the APTA?

The APTA as a Means of Career Development (cont'd)

Other national activities PTA caucus leadership APTA advisory panels Advisory panel of PTAs Reserved spots on advisory panels Education Membership Recruitment and Retention Practice Item writer for FSBPT PTA licensure exam Reviewer for CAPTE PTA program accreditation

HIPAA OVERVIEW

PROTECTED HEALTH INFORMATION (PHI) Any information oral or recorded that is created or received by a health care provider. Relates to past, present, or future physical or mental condition of patient. Provision of health care to an individual. Past, present, or future payment for the provision of health cares. Law must be applied by anyone who has access to PHI Penalties (THIS IS A FEDERAL OFFENSE) Noncompliance with security standards carries civil penalty of $100 per violation up to $25,000 per person for all identical violations in a calendar year. Criminal penalties if a person knowingly obtains or discloses any individuals identifiable health information fine up to $50,00 and/or imprisonment up to one year. If states have higher standards they override the basic standards set for HIPAA Penalties (THIS IS A FEDERAL OFFENSE) If offenses are committed under false pretenses, fine up to $100,000 and imprisonment up to five years. Offender has intent to sell, transfer, or use health information for commercial advantage, personal gain, or malicious harm, maximum fine $250,000 and imprisonment up to 10 years Exposure to lawsuits, loss accreditation, audits by HHS, damage to business

DOCUMENTATION for the PTA

PT is more of an evaluator, consultant, manager, practitioner Medical diagnosis (label pathology) PT diagnosis (ID's patho kinesiology) PTA provides treatment under guidance and supervision of PT - PTA SCOPE of WORK PT services must be efficient and cost-effective

BASIC REQUIREMENTS

PT is responsible for directing & supervising PTA PTA MUST work "under direction and supervision of a PT" Must have knowledge of: State Laws APTA policies and positions Payer source guidelines

PTA Representation Within APTA Governance

PTA Caucus (created 2005) Meets in person twice per year One PTA representative from each state Can bring motions to House of Delegates Advisory panels (created 2005) Appointed positions Advisory panel of PTAs Reserved PTA spots on other advisory panels

PT MEDICAL RECORD components Visit / Encounter / Daily Note (PT & PTA)

Patient/client self-report (as appropriate) and subjective response to previous treatment Identification of specific interventions provided, including frequency, intensity, and duration as appropriate Changes in patient/client impairment, functional limitation, and disability status as they relate to the plan of care. Response to interventions, including adverse reactions, if any. Factors that modify frequency or intensity of intervention and progression toward anticipated goals, including patient/client adherence to patient/client-related instructions. Communication/consultation with providers/patient/client/family/ significant other. Documentation to plan for ongoing provision of services for the next visit(s), which is suggested to include, but not be limited to: The interventions with objectives Progression parameters Precautions, if indicated Signature, title, and license number (if required by state law)

Performance / Quality Improvement

Performance improvement is defined as a series of administrative and programmatic processes designed for the achievement of organizational and individual results. The goal of PI is to provide high quality, measurable and sustainable services Quality Improvement (QI) is an integrative process that links knowledge, structures, processes and outcomes to enhance quality throughout an organization. -National Committee for Quality Assurance

DOCUMENTATION STANDARDS

Physical therapy examination evaluation diagnosis prognosis plan of care shall be documented, dated, and authenticated by the physical therapist who performs the service. Other notations or flow charts are considered a component of the documented record but do not meet the requirements of documentation in or of themselves. Interventions provided by the physical therapist or selected interventions provided by the physical therapist assistant under the direction and supervision of the physical therapist are Documented Dated Authenticated by: physical therapist Or when permissible by law physical therapist assistant. Students may document when the record is additionally authenticated by the physical therapist or, when permissible by law, by a physical therapist assistant.

BODY FUNCTION AND STRUCTURES

Physiological and psychological function of body systems Very specific recording of detailed functional abilities and impairments Not linked to cause. For example, fluency and rhythm of speech functions - could be from stuttering, stroke, or autism

DEFINITIONS

Policies are principles, rules, and guidelines formulated or adopted by an organization to reach its long-term goals. They are designed to influence and guide major decisions, actions, and activities. Procedures are the methods used to put policies into action in day-to-day operations.

APTA "DEFENSIBLE DOCUMENTATION"

Poor legibility. Incomplete documentation. No documentation for date of service. Abbreviations - too many, cannot understand. Documentation does not support the billing (coding). Does not demonstrate skilled care. Does not support medical necessity. Does not demonstrate progress. Repetitious daily notes showing no change in patient status. Interventions with no clarification of time, frequency, duration.

P value

Probability level The level at which the difference is due to chance. Typically set at .05 (5 times out of 100) If p value > .05 (trial- difference is due to chance) If p value <.05 (trial difference is due to intervention)

Current Utilization of the PTA

Professional When used in APTA documents, refers only to the physical therapist Physical Therapist Practice Practice is conducted by the physical therapist Scope of practice (PT) versus scope of work (PTA) But PT practice includes utilization of PTAs who assist with selected components of intervention Professionalism in Physical Therapy: Core Values Accountability Altruism Compassion/caring Excellence Integrity Professional duty Social responsibility Values-Based Behaviors for the PTA Altruism Caring and compassion Continuing competence Duty Integrity PT/PTA collaboration Responsibility Social responsibility

Americans with Disabilities Act (ADA) - 1990

Prohibits discrimination on the basis of a physical or mental disability in the following Employment Companies with 15 or more employees cannot discriminate based on a disability if a person is qualified to perform a job. The employer must make accommodations to allow the employee to perform the job, unless it causes "undue hardship". State and Local Government Activities People with disabilities must have equal opportunity to benefit from government services and activities such as recreation, health care, social services and voting. Public Transportation Public transportation services such as buses and trains must accommodate people with disabilities. Public Accommodations Applies to restaurants, retail stores, hotels, movie theatres, convention centers, zoos, day care centers, sports stadiums, fitness clubs, etc. ECU's are environmental control units. They are a type of assistive technology that allows people to control many electrical devices in their home from one central location. Public Accommodations "Undue hardship" means that a company is not legally obligated to make ADA-related changes to their office/place of business, if those changes would put the company in serious financial jeopardy. Rise : run for an outdoor ramp is 1:20. Therefore, to climb 4 STEPS @ 7 inches per step = 28 inches, the ramp would need to be 28 x 20 inches long. That's 46'8". Telecommunications Applies to telephone and television access for people with hearing and speech disabilities. Victims of discrimination can file a complaint with the Equal Employment Opportunity Commission (EEOC) or the U.S. Department of Justice.

KEYS to GOOD MEDICAL DOCUMENTATION CONT.

Punctuation Hyphens (-) should not be used as they can be confused with a minus sign NO: Pt has strength of 2- better than last week YES: Pt. has strength of 2 / 5; better than last week Semicolon (;) can be used to connect phrases NO: Pt notes decreased pain with ROM. Pt notes increased ability to complete ADL. YES: Pt. notes decreased pain with ROM; increased ability to complete ADL Colons (:) can replace the word " is " NO: Pt. R shoulder ROM is 0-74˚ YES: R shoulder ROM: 0-74. Writing verbal orders received Date / time / order 1-23-07/2:47pm/Pt. WBAT c RW. v.o. Dr. Slettehaugh / Daryl Menke PT, DPT, MCMT 1ST Person Language Disability does not define the person AVOID: "paralyzed patient" "amputee" " the CVA patient" YES: "male patient with T12 SCI" "Mr. Jone's left BKA" "Marjorie's CVA"

QA & QI -They are not the same!!!

Quality Assurance: Reactive; works on problems after they occur Regulatory Led by management One point at a time Quality Improvement: Proactive - works on processes before problems occur Self-determined Led by staff Continuous Exceeds expectations

FLOW SHEETS

Quick entries Very little sentence writing Typically documents exercises, distance walked, ect. Limited information MUST make entry into objective section as outlined in previous slides

Using an Ethical Decision-MakingModel

RIPS Model of Ethical Decision Making Realm Individual, organizational/institutional, societal Individual Process Moral sensitivity, judgment, motivation or courage Situation Issue/problem, dilemma, distress, temptation, silence

PT PRACTICEORGANIZATIONALPLANNING

Read the APTA: CRITERIA FOR STANDARDS OF PRACTICE FOR PHYSICAL THERAPY

Advanced Skill Development Through the APTA

Recognition of Advanced Proficiency for the Physical Therapist Assistant Acute Care Cardiopulmonary Geriatrics Oncology Pediatrics Wound management PTA pathways/service delivery models

Listening Skills "Active listening"

Restatement: Repeating back without clarification Patient: "I'm not going to therapy today! I hate exercising!" PTA: "You don't want to go to physical therapy today?" Reflection: Interpreting the content PTA: "You don't like exercising. The exercises must be very difficult." Clarification: Asking if interpretation is correct PTA: "Is that what you don't like about physical therapy?"

SOAP FORMAT

S - Subjective O = Objective A = Assessment P = Plan

HHS SECURITY REGULATIONS

SECURITY REQUIREMENTS ADMINISTRATIVE PROCEDURES: To guard data integrity, confidentiality, and availability Must be documented, formal practices (P&P's) PHYSICAL SAFEGUARD: Documented formal practices to manage selection and execution of security measures. TECHNICAL SECURITY SERVICES: Including all processes to protect, control, and monitor information access.

MODELS of DOCUMENTATION

SOAP (Subjective, Objective, Assessment, Plan ) MOST COMMONLY USED DEP ( data ; evaluation ; performance) PSPG ( problem ; status ; plan ; goals) PSP ( problem ; status ; plan) Paragraph / Narrative

Sensivity and Specificity

Sensitivity The ability of the test to correctly identify the proportion of individuals who truly have the disease or condition. a true positive Specificity The ability of the test to correctly identify the proportion of individuals who do not have the disease or condition. a true negative

Other Documentation Formatsand Organizational Styles

Source-oriented Each discipline writes their own note in their own section (PT / Speech / Nursing / Dr.) Problem-oriented formats Categorized based on patient diagnosis, goals, or problems and each

Patient Reactions to Illness and Injury

Stages of grief (Kübler-Ross) Denial Anger Bargaining Depression Acceptance What are some other emotions a patient might experience as a reaction to illness or injury?

SUPERVISION OF STUDENTS

State law Practice act may be silent. APTA requirements Review: What does APTA recommend? Medicare requirements Dependent on type (A vs. B) Dependent on setting Recent changes to SNF rules

State Regulation: Practice Acts

Statutes Written and passed by state legislature Rules Administrative clarification of statutes Usually written by the state governing body that oversees the actions of that profession Federation of State Boards of Physical Therapy (FSBPT) National organization formed to help state boards work together They recommend PTA are regulated at the Certification Level

OBJECTIVE

Step-by-step description of The interventions delivered The patient's response to interventions Functional performance level Factual and reproducible Results of tests and measurements Type of education or assistance given Paints a picture of the patient and treatment Findings from assessment / testing (Range of Motion / Strength / Balance/ Gait / etc) Description of FUNCTION Quality of movement "Poor right shoulder ROM continues to limit his ability to put his shirt on each morning" How the function is being affected by the limitations? Level of assistance required to complete the task What equipment is needed? Qualifiers of the distance / weight / height of skills performed Environmental barriers encountered (carpet, ramps, etc.) What happened at PT today Vital signs Treatment provided (ROM / Manual Therapy / Massage, / Modality / Exercise) Test & Measurements completed Functional skills practiced Objective observations & Response to the therapy What you see, feel, palpate, etc. Examples include: Description of gait pattern Bulging lump in biceps area Redness around the knee joint Information should be reproducible What did you do (Estim, massage, exercises, etc.)? How much did you do it (number of reps, estim time, etc.)? What part of the body was it done to? What tissues were you targeting? What were the settings on the maching (estim, US, etc.)? What position was the patient in? What was the purpose of your treatment? Did you do anything outside the standard protocol for this type of treatment? Did anything unique occur that others should be aware of? Relates to the current problem Determines progress "See ankle ROM measurements from initial evaluation on 12-10-2015" Patient education activities performed / instructed Don't write what you did but rather what the patient did NO: "Provided patient with home exercise program (HEP)" YES: "Following instruction, patient demonstrated competence in performance of HEP per instructions (see handout in chart)"

PT MEDICAL RECORD components Visit / Encounter / Daily Note (PT & PTA) CONT.

Subjective complaints / descriptive / numerical pain / % of improvement Complicating factors Flow sheet (show progression and skill) Observation of movement / measurements / function gain - loss / skill need / education of patient Type and amount of manual, visual, verbal cues Why needed Constant verbal and tactile cues for shldr flex without substitution. Ther ex resulted increase shldr flx to 120 to comb hair, still unable to reach into cupboards at home. Factors that modify frequency / intensity / progression Performing shldr flex and abd ex incorrectly resulting increased impingement. Painted bedroom with repeated overhead mvts increased pain Computer station ergonomic corrections not made, enhances poor posture and muscle imbalances aggravating sx Statement of clinical decision and problem solving Poor control and contraction transverse ab muscles resulting in continued compression and sheering lumbar with pain and radicular sx requires neuro-ed ex and educ. Poor blood sugar control resulting fatigue and avoidance of exercise. Speak to MD. Quad control in open chain good, transition into controlled functional closed chain in preparation for running.

Leadership Traits (Kouzes and Posner)

Successful leaders will Envision change Inspire others to share in the vision Model desired behaviors with words and actions Encourage others Challenge existing processes Empower others to take action

Intervention

The delivery of "various physical therapy procedures and techniques to produce changes in the condition that are consistent with the diagnosis and prognosis...contingent on the timely monitoring and of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes." (Guide to Physical Therapist Practice)

PLAN

The future: What happens next Need for consultation with PT or other health-care professionals Equipment to be ordered Focus of next/upcoming intervention sessions Reiteration of goals but not progress toward them This is a statement of what needs to be done before or during the next session, such as: What will happen at next session - BE SPECIFIC PT needs to reassess the patient's plan of care When next session is scheduled - How many session remain Referral to other services would be appropriate for this section Usually written in the future tense...will is a common verb! Include frequency of therapy, how many visits are left, when discharge is anticipated, etc Somewhere in this section should be a statement of the collaboration between the PT and PTA: "Will begin ambulation training per PT goal in initial eval" "Will consult with PT regarding patient's continued complaints of pain despite improving objective data."

HEALTH CARE SYSTEMS

The goals for health systems, according to the World Health Report 2000 - Health systems: improving performance (WHO, 2000): Good health Responsiveness to the expectations of the population Fair financial contribution

Differentiating Between Legal and Ethical Issues

The law pertains to everyone in a given society. Professional standards / ethical codes technically only apply to those who are part of a given professional organization. However, they may be used in a court of law to demonstrate expected professional behavior and standards of care. A clinician's inappropriate action can be dealt with in up to four ways. Criminal court If a crime has been committed Civil court If health-care malpractice has occurred Licensing board If a practice act has been violated Professional organization If an ethical violation has occurred (see Chapter 7) Unethical may not be illegal Illegal is usually unethical

HEALTH / MEDICAL RECORDS

The main uses of the medical record are: to document the course of the patient's illness and treatment; to communicate between attending doctors and other health care professionals providing care to the patient; for the continuing care of the patient; for research of specific diseases and treatment; and the collection of health statistics.

Blinding

The patient is unaware which group he/she is allotted to Double blind- Neither pt or the researcher is aware of the group allocation

Lifelong Learning (APTA)

The systematic maintenance and improvement of knowledge, skills, and abilities through one's professional career or working life. Lifelong learning is the ongoing process by which the quality and relevance of professional services are maintained." Continuing to develop skills and knowledge is both an APTA expectation and necessary trait for success in the clinical setting. PTAs "are obligated to engage in lifelong learning and are responsible for meeting and exceeding contemporary performance standards within their scope of work."

BASIC CONSIDERATIONS SOAP

This is a legal document! All documentation you make becomes a part of the patient's medical record It provides protection to both the patient and caregiver if questions about the patient's care In a legal proceeding, this document can be subpoenaed as evidence Communicate professionally and intelligently in all communications regarding a patient Holds health - care providers accountable for quality of care Documentation is the way your facility receives reimbursement for your services and insurance companies will not hesitate to deny if you don't provide clear information and document progress "If it isn't written, it didn't happen!"

MINIMUM NECESSARY

To use or disclose/release only the minimum necessary to accomplish intended purposes of the use, disclosure, or request. Requests from employees Identify each workforce member who needs to access PHI. Limit the PHI provided on a "need-to-know" basis. Requests from individuals not employed Limit the PHI provided to what is needed to accomplish the purpose for which the request was made.

Patient Bill of Rights (1973)

Treated with respect, dignity, nondiscriminatory Safe and appropriate Understandable language Know identity of healthcare provider Choice Right of Refusal Privacy & Confidentiality Freedom to file complaint or grievance

Activities and Participation (cont.)

UN Washington Group approach Activities - tasks an individual can do that require multiple body functions Participation - higher order activities that involve integration in the community WHO approach Activities - what people can do inherently without assistance or barriers Participation - functioning taking into account the impact of barriers and facilitators in the environment

Individual Roles and Responsibilities

Ultimate responsibility for the PT patient care is the Physical Therapist PTA's role in patient progression It is appropriate for PTA to progress patient's intervention within existing plan of care. Different PTs may have different expectations/parameters for progression within the plan of care. Always necessary for PTA to consult with PT for any change outside plan of care.

The APTA Vision statement

Updated in 2013 Transforming society by optimizing movement to improve the human experience.

ELECTRONIC HEALTH RECORD (EHR)

Use of computer technology to document In response to Executive order by President Bush in 2004 Medicare & Medicaid Laws 2009 Commercial systems that vary from facility to facility Advantages Ease of storing data Legibility Access Consistency Disadvantages Costs Training Different systems Security

BIOPSYCHOSOCIAL MODEL

Views disability as an interaction between features of the person and features of the overall context in which the person lives. ICF is based on this model.

DEVELOPMENT OF PTA

When was the position of "physical therapist assistant" first developed? Approved by APTA, the first two programs started in 1967 First graduates in 1969 The PTA position was created in response to a need for a formally, consistently educated, skilled health-care worker to whom PTs could delegate components of physical therapy intervention Why was the title changed from physical therapy assistant? To reflect that the role is to directly assist the therapist in the delivery of physical therapy services According to Watts, what are the primary factors that PTs should take into consideration when deciding what tasks can be performed by the PTA? Complexity of the task Decision making vs. doing Risks involved Criticality of the patient Purpose of the task Experience/knowledge base of PTA

EBP steps

assess pt ask the right question access the evidence appraise evidence apply evidence audit clinical practice

EBP

best research evidence, clinical expertise, patient values and preferences

THE COMMUNICATION PROCESS

sender, message, receiver, feedback

What are the most common ways we communicate?

spoken word written word body language visual images

Levels of evidence best to worst

systematic reviews randomized controlled trials cohort studies case control studies case series case reports editorials expert opinion

EBP MOST USEFUL RESEARCH

validity reliability patient center clinical studies safety efficacy