Documentation Basics for the Physical Therapist Assistant

Core Texts for PTA Education

Third Edition

Documentation Basics for the Physical Therapist Assistant

Core Texts for PTA Education

MIA L. ERICKSON, PT, EDD, CHT, ATC Midwestern University

Physical Therapy Department Glendale, AZ

REBECCA MCKNIGHT, PT, MS Educational Consultant Reach Consulting, LLC

Forsyth, MO

www.Healio.com/books

Copyright © 2018 by SLACK Incorporated

Dr. Mia L. Erickson and Rebecca McKnight have no financial or proprietary interest in the materials presented herein.

All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher, except for brief quota- tions embodied in critical articles and reviews.

The procedures and practices described in this publication should be implemented in a manner consistent with the professional standards set for the circumstances that apply in each specific situation. Every effort has been made to confirm the accuracy of the information presented and to correctly relate generally accepted practices. The authors, editors, and publisher cannot accept respon- sibility for errors or exclusions or for the outcome of the material presented herein. There is no expressed or implied warranty of this book or information imparted by it. Care has been taken to ensure that drug selection and dosages are in accordance with currently accepted/recommended practice. Off-label uses of drugs may be discussed. Due to continuing research, changes in government policy and regulations, and various effects of drug reactions and interactions, it is recommended that the reader carefully review all materials and literature provided for each drug, especially those that are new or not frequently used. Some drugs or devices in this publication have clearance for use in a restricted research setting by the Food and Drug and Administration or FDA. Each professional should determine the FDA status of any drug or device prior to use in their practice.

Any review or mention of specific companies or products is not intended as an endorsement by the author or publisher.

SLACK Incorporated uses a review process to evaluate submitted material. Prior to publication, educators or clinicians provide impor- tant feedback on the content that we publish. We welcome feedback on this work.

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Instructors: Documentation Basics for the Physical Therapist Assistant, Third Edition Instructor’s Manual is also available from SLACK Incorporated. Don’t miss this important companion to Documentation Basics for the Physical Therapist Assistant, Third Edition. To obtain the Instructor’s Manual, please visit http://www.efacultylounge.com

CONTENTS About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Chapter 1 Disablement and Physical Therapy Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 2 The Physical Therapy Episode of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Rebecca McKnight, PT, MS

Chapter 3 Reasons for Documenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 4 Documentation Formats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 5 Electronic Medical Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 6 Basic Guidelines for Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Rebecca McKnight, PT, MS and Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 7 Interpreting the Physical Therapist Initial Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Rebecca McKnight, PT, MS

Chapter 8 Writing the Subjective Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Rebecca McKnight, PT, MS

Chapter 9 Writing the Objective Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Rebecca McKnight, PT, MS

Chapter 10 Writing the Assessment and Plan Sections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Rebecca McKnight, PT, MS

Chapter 11 Payment Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 12 Legal and Ethical Considerations for Physical Therapy Documentation . . . . . . . . . . . . . . . . 119 Mia L. Erickson, PT, EdD, CHT, ATC

Chapter 13 Documentation Across the Curriculum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Mia L. Erickson, PT, EdD, CHT, ATC

Traumatic Brain Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Tracy Rice, PT, MPH, NCS

Spinal Cord Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Tracy Rice, PT, MPH, NCS

Appendix: Abbreviations and Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155

Instructors: Documentation Basics for the Physical Therapist Assistant, Third Edition Instructor’s Manual is also available from SLACK Incorporated. Don’t miss this important companion to Documentation Basics for the Physical Therapist Assistant, Third Edition. To obtain the Instructor’s Manual, please visit http://www.efacultylounge.com

ABOUT THE AUTHORS Mia L. Erickson, PT, EdD, CHT, ATC, is a faculty member in the Physical Therapy Department at Midwestern

University in Glendale, AZ. Mia earned a bachelor’s degree from West Virginia University in secondary education in 1994 and a master of science degree in physical therapy from the University of Indianapolis in 1996. Mia earned a doctoral degree in education from West Virginia University with an emphasis on curriculum and instruction in 2002. Her clinical practice is in the area of hand and upper-extremity rehabilitation.

Rebecca McKnight, PT, MS, received her bachelor of science degree in physical therapy from St. Louis University in 1992 and her postprofessional master of science degree from Rocky Mountain University of Health Professions in 1999. She taught at Ozarks Technical Community College for 14 years, serving as Program Director for 9 of those years. Rebecca is an active member of the American Physical Therapy Association and is a former chair of the Physical Therapist Assistant Educators Special Interest Group of the education section. Rebecca has spoken at many national meetings on physical therapist assistant curriculum design and programmatic assessment. She is the 2009 recipient of the F.A. Davis Award for Outstanding Physical Therapist Assistant Educator. Rebecca has been providing educational consultation in the areas of curriculum design, development, and assessment for physical therapist assistant programs nationwide since 2007.

PREFACE We would like to thank you for choosing the Third Edition of Documentation Basics for the Physical Therapist Assistant.

We think that you will find some substantial changes that make this edition more modern, reflecting contemporary prin- ciples in documentation. Two of the biggest changes are incorporation of the International Classification of Functioning, Disability and Health (ICF) disablement model (vs other models that have been discussed in previous editions) and further integration of the electronic medical record. The ICF serves as the framework for several important aspects of this text. Throughout, we encourage readers to really think about disablement and disablement concepts when writing notes. This includes documenting impairments in body structure and function in addition to activity limitations and participation restriction. We also encourage the reader to frequently note improvements in impairments, activity limitations, and par- ticipation restrictions brought on by the intervention provided in objective terms so that others reading the documentation can see the improvement.

This edition has been updated in its discussion of the electronic medical record. In addition to describing the differ- ences in documentation methods using a computer vs a paper chart, this edition features a stand-alone chapter on the electronic medical record. It walks the reader through differences in the electronic health and medical records and dis- cusses the rationale for change to electronic record keeping. The book also incorporates some evidence tied to benefits and challenges of computerized documentation. We were fortunate enough to have WebPT® (Phoenix, AZ) allow us to integrate screen shots from its computerized documentation system. This enables the reader to see what a screen would look like in various parts of the medical record.

We continue to incorporate concepts related to documenting the rationale for treatment and note how the unique skills of the physical therapist assistant were used in patient management. Examples, or “how-tos,” are also provided. We feel like these changes are unique to our text and can help readers to understand these important aspects of documentation in today’s payer system.

While we continue our instruction in writing a note using the SOAP (subjective, objective, assessment, and plan) struc- ture, we recognize and point out its flaws. We still believe that understanding parts of notes using the SOAP acronym can help students to learn the fundamentals and then, when they get to the clinical site, they can integrate their knowledge into the software or charting system used at that site.

Again, we are happy to provide you with this updated version of our book, and we hope that you enjoy it, whether you are using it as a physical therapist assistant student, a physical therapist assistant educator, or a clinician.

Mia L. Erickson, PT, EdD, CHT, ATC

Erickson ML, McKnight R. Documentation Basics for the Physical Therapist Assistant, Third Edition (pp. 1-7)

© 2018 SLACK Incorporated 1

Disablement and Physical Therapy Documentation

Chapter 1

After reading this chapter, the reader will be able to do the following: 1. Define disablement. 2. Define terminology used in the International

Classification of Functioning, Disability and Health (ICF).

3. Differentiate between impairment, activity limitation, and participation restriction.

4. Define documentation. 5. Describe the need for common language in physical

therapy documentation. 6. Describe how disablement concepts can be integrated

into physical therapy documentation. A traditional approach to defining a person’s health

comes from the biomedical model in which health means free or absent from disease.1 The biomedical model implies that accurate diagnosis and identification of the patient’s biological defects can directly lead to selection of interven- tions that will maximize health outcomes.1 In this model, however, there is little emphasis on how the disease affects

the person’s ability to function or participate within society on a daily basis. Over the last few decades, many reha- bilitation professionals have shifted their focus away from managing the disease or pathology and have moved toward managing the consequences of the disease or condition. It has become more common to focus on these consequences as they pertain to the individual’s ability to carry out tasks and function within society. Assessing functional perfor- mance and describing functional status are now primary components of the physical therapist’s examination of the patient. Verbrugge and Jette2 described the consequences that chronic and acute conditions have on specific body system function and on a person’s ability to act in neces- sary, usual, expected, and personally desired ways in his or her society as disablement. These authors explained that disablement is a “process,” indicating that it is dynamic, or a trajectory of functional consequences over time. A more contemporary approach to physical therapy patient man- agement is to incorporate disablement and disablement concepts.

Individuals and groups throughout the world have developed disablement frameworks. Disablement frame- works are useful for providing a common language for health care providers, and they can serve as a basic archi-

CHAPTER OBJECTIVES

KEY TERMS Activity | Activity limitation | American Physical Therapy Association | Biomedical model | Body functions | Body structures | Contextual factor | Disablement | Documentation | Environmental factor | International Classification of Functioning, Disability and Health | International Classification of Diseases, Tenth Revision | Participation | Participation restriction | Personal factor | Physical therapist

KEY ABBREVIATIONS APTA | ICD-10 | ICF | PT | WHO

Chapter 12

tecture for research, policy, and clinical care.2 In addi- tion to providing infrastructure, disablement frameworks define health in terms that go beyond the patient’s medical diagnosis or disease, acknowledging the importance of societal, psychological, and physical functioning. Rather than placing the measure of health on the disease process itself, these models have helped providers to shift toward understanding an individual’s ability to carry out neces- sary life tasks and to function within society. Disablement frameworks have attempted to delineate a pathway from pathology to functional outcome while recognizing the social, psychological, and environmental factors that can facilitate or interfere with the pathway.2 The purpose of this chapter is to introduce you to the disablement frame- work used in physical therapy practice and to introduce the purpose of using disablement and disablement concepts in clinical documentation.

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH

The ICF, originally known as the International Classification of Impairments, Disabilities, and Handicaps, was endorsed by the 54th World Health Assembly and released in 2001. The ICF provides a uniform, standard language for describing an individual’s health and health- related state that moves beyond his or her diagnosis.3 In 2008, the American Physical Therapy Association (APTA) House of Delegates voted to endorse the ICF and, as a result, APTA publications, documents, and communications have been updated to incorporate the ICF language (Example 1-1).4 Therefore, the ICF serves to provide a common lan- guage for physical therapists to communicate.

Example 1-1 The following definitions have been endorsed by the World Health Organization as part of the ICF3:

• Functioning is an umbrella term that includes all body functions, activities, and participation. • Disability serves as an umbrella term for dysfunction at any one or more of the following levels: impairment, activity limitation, and participation restriction.

• Body functions are physiological functions of the body (including psychological function). • Body structures are anatomical bodily structures, such as organs and limbs. • Impairments are problems with body functions (physiological, psychological) or structures, such as a deviation or loss.

• Activity is the execution of a task or activity by an individual. • Activity limitations are difficulties that might be encountered by an individual who is attempting to complete a task or carry out an activity.

• Participation is involvement in a life situation, such as work or school. • Participation restrictions are problems an individual might face while involved in life situations.

• Contextual factors are the complete factors that make up a person’s life and living, including his or her background.

• Environmental factors are the physical, social, and attitudinal environmental in which people live and carry out their lives. These include things immediate to the individual, such as his or her home or workplace, and the larger social context, such as government agencies designed to assist people with disabilities.

• Personal factors are factors specific to the individual and his or her background. These include things such as age, gender, social habits, health habits, upbringing, and coping strategies.

Disablement and Physical Therapy Documentation 3

In the ICF, the individual’s health or health-related state is described in terms of function and disability. What the individual can do is known as functioning, or the positive aspects of health. What the individual cannot do is known as disability, or the negative aspects of health (Figure 1-1).3 Function and disability comprise Part 1 of the ICF. Part 1 is further divided into the following 2 components: (1) body functions (physiological function) and body struc- tures (anatomical structures) and (2) activities and partici- pation (Figure 1-2).3 In categorizing an individual’s health according to the ICF, a health care provider would describe body structures and functions that are intact and those that are not intact. Any deviation(s) from normal body structure and/or function are known as impairments. For the activities and participation component, the exam- iner identifies functional tasks that the individual can do (known as activities) and those that he or she cannot do (known as activity limitations). The examiner also identi-

fies life roles that the individual can carry out (known as participation) and those that he or she cannot carry out (known as participation restrictions; see Figure 1-1).3

The ICF also accounts for contextual factors that might facilitate or impede the patient’s function. These appear in Part 2, which also includes environmental and personal factors that affect the individual’s functioning and dis- ability. Environmental factors are external factors that are either within the individual’s immediate environment or part of a larger social structure and that affect the individual’s ability to participate in society. These might be facilitators, which enhance participation, or barriers, which deter participation. Environmental factors include things such as physical structures (eg, ramps, stairs, curbs). Personal factors are those that are unique to the individual, such as attitude, mood, or family support (see Figure 1-2).3

Figure 1-1. Overview of the International Classification of Functioning, Disability and Health.3 The string of boxes on the left repre- sents the positive aspects of the health state or condition. The string of boxes on the right rep- resents deviations from normal, or the negative aspects of health.

Body-level

Individual- level

Societal- level

ICF

Health and Health- Related States

Function: What the individual

CAN do (Positive Aspects of

Health)

Disability: What the individual

CANNOT do (Negative Aspects

of Health)

Body tissues and/ or structures that

are intact and functioning

(Normal)

Body tissues and/ or structures that are not intact or

functioning (Impairments)

Tasks an individual CAN carry out

(Activities)

Tasks an individual CANNOT carry out

(Activity Limitations)

Roles in which an individual CAN

participate (Participation)

Roles in which an individual CANNOT

participate (Participation Restrictions)

Chapter 14

The ICF is part of a “family” of classifications created by the World Health Organization (WHO) known as the WHO Family of International Classifications.5 This family also includes the International Classification of Diseases, Tenth Revision (ICD-10), a classification system for medical diagnoses and diseases. The ICD-10 is the diagnostic clas- sification standard for all clinical and research purposes. It defines the universe of disease, disorders, injuries, and other related health conditions, listed in a comprehensive format.6 The ICF and ICD-10 are meant to complement each other in that the ICD-10 provides a catalog of medical diagnoses, diseases, disorders, and health conditions and the ICF provides corresponding information on function and disability. Used together, they provide a broader picture of an individual’s health.7

PHYSICAL THERAPY AND DISABLEMENT The ICF provides clinicians with standardized termi-

nology and a framework to aid in exploring the impact of disease or injury on an individual’s daily life. More spe- cifically, physical therapy providers can use the ICF to help understand the consequences of the disease or condition on the body systems and the impact on the individual’s activ- ity level and participation within society. Consideration

of disablement when working with patients helps physical therapy providers to realize more complex functional and social issues that patients face.

Individuals in need of physical therapy services often have a disease or injury with resulting impairments in body structure(s) and/or function(s), activity limitations, and participation restrictions that are identified during the physical therapist’s examination. Impairments can be limitations in range of motion, strength, endurance, or balance, to name a few. But to see how the patient’s abil- ity to participate in society has been compromised, the examination must go beyond the impairment level. It is our responsibility to understand how impairments affect the patient’s day-to-day activities and participation in a variety of settings and situations; therefore, the physical therapist’s examination of patient function includes assessment of the following: (1) activities such as bed mobility, transfers, hygiene, self-care, and home management (eg, yardwork, household cleaning); and (2) participation such as the abil- ity to work, go to school, play, and participate in commu- nity activities (eg, going to the grocery store or bank). By understanding an individual’s impairments and his or her activity limitations and participation restrictions, we can better understand the degree of disability associated with the pathology for the individual patient.

Figure 1-2. The International Classification of Functioning, Disability and Health3 from the WHO. (Reprinted with permis- sion from the WHO.)

Disablement and Physical Therapy Documentation 5

DOCUMENTATION AND DISABLEMENT Documentation, otherwise known as medical record

keeping, has been defined as “any entry into the individu- al’s health record, such as a(n) consultation reports, initial examination reports, progress notes, flow sheets, checklists, re-examination reports, or summations of care, that identi- fies the care or services and the individual’s response to intervention.”8 Complete documentation also includes the physician prescription(s) and certification(s), communica- tion with other care providers, copies of exercise programs or patient instructions, and any other disciplines’ notes or comments that support the interventions.9

As you will read in subsequent chapters, documenta- tion will serve many purposes, but, regardless of the pur- pose, your documentation should reflect disablement. One reason for integrating disablement concepts in physical therapy documentation is to achieve consistency in termi- nology because our notes are the sole record of the episode of care provided to each patient or client. Another reason is to show the reader how the patient’s pathology and impair- ments influence his or her activities and participation in daily life. Disablement concepts serve as a foundation for this text. Throughout the chapters, you will be reminded of the following 3 important disablement concepts that should be integrated into your clinical documentation: 1. Documentation should reflect not only measures of

impairment, but also measures of activity limitations and participation restrictions.

2. Documentation should describe how the patient’s impairments relate or contribute to his or her activity limitations and participation restrictions.

3. Documentation should explain how physical therapy interventions are bringing about changes in impair- ments, activity limitations, and participation restric- tions that relate to the patient’s therapy goals.

REFERENCES 1. MacDermid JC, Law M, Michlovitz SL. Outcome mea-

surement in evidence-based rehabilitation. In: Law M, MacDermid JC, eds. Evidence-Based Rehabilitation: A Guide to Practice. 3rd ed. Thorofare, NJ: SLACK Incorporated; 2014:65-104.

2. Verbrugge LM, Jette AM. The disablement process. Soc Sci Med. 1994;38(1):1-14.

3. World Health Organization. International Classification of Functioning, Disability and Health: ICF. Geneva: World Health Organization; 2001.

4. American Physical Therapy Association. International Classification of Functioning, Disability, and Health. APTA Website. http://www.apta.org/ICF/. Updated August 23, 2013. Accessed October 24, 2016.

5. Madden R, Sykes C, Ustun TB. World Health Organization Family of International Classifications: definition, scope, and purpose. World Health Organization Website. http://www. who.int/classifications/en/FamilyDocument2007.pdf?ua=1. Updated February 2, 2012. Accessed October 24, 2016.

6. World Health Organization. Classifications: International Classification of Disease. WHO Website. http://www.who. int/classifications/icd/en/. Updated June 29, 2016. Accessed October 24, 2016.

7. Escorpizo R, Bemis-Dougherty A. Introduction to spe- cial issue: a review of the International Classification of Functioning, Disability and Health and physical therapy over the years. Physiother Res Int. 2015;20(4):200-209.

8. American Physical Therapy Association. Guide to Physical Therapist Practice 3.0. APTA Website. http://guidetoptprac- tice.apta.org/content/1/SEC2.body. Updated August 1, 2014. Accessed October 24, 2016.

9. Redgate N, Foto M. Pay by the rules: avoid Medicare audits and reduce payment denials with a sound strategy and prop- er documentation. Physical Therapy Products. 2003;October/ November:28-30.

Chapter 16

REVIEW QUESTIONS 1. How is a person’s health determined today as opposed to 5 decades ago?

2. In your own words, describe disablement.

3. According to the ICF, what is the difference between an impairment, an activity limitation, and a participation restriction?

4. Why is there a need for disablement models today? Why are they important to you?

5. What is physical therapy documentation? What does it include?

6. Give some examples of ways a physical therapist assistant can incorporate disablement concepts into his or her documentation.

7. Look at the examples below. Determine if each would be considered an impairment in body function or structure, an activity limitation, or a participation restriction.

Taking a bath Going to school Brushing teeth Limited shoulder motion Walking in the community Going to the grocery store Ascending/descending stairs Turning a door knob Poor endurance Writing Working Poor balance Donning socks Bathing

Disablement and Physical Therapy Documentation 7

Read the following scenarios and identify the impairments, activity limitations and participation restrictions.

8. You are working with a 70-year-old male who had a total hip replacement 3 weeks ago. He is …

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