2020 EMR and SOAP-3

Documentation

Electronic Medical Record/Electronic Health Record
Writing Patient Goals
SOAP Note

February 27, 2020
PT 635: PT Professional Practice II

Why is documentation important?

´ Planning and provision of physical therapy services
´ Communication between providers
´ Record of care provided and outcome of interventions
´ Demonstration of compliance with

federal/state/payer/local regulations
´ Evidence in potential legal challenges
´ Justification of services and reimbursement by third-

party prayers
´ Research purposes

http://integrity.apta.org/Documentation/#

What is “Defensible Documentation?”

´ Documentation that is comprehensive, accurate, and
clear

´ Documentation that communicates:
´Skilled Care
´Evidenced-based care
´Medical Necessity
´Progress
´Accurate coding/billing

Conveying Medical Necessity and
Skilled Intervention

´ Documentation must convey that interventions provided require skills
of a PT or PTA

´ Daily note is not just a listing of what treatments took place; should
include:
´ type and level of skilled assistance given
´ the clinical decision- making utilized
´ continued analysis of progress or lack of progress

´ Skilled care can be demonstrated through documentation of:
´ Patient response to intervention
´ Functional progress
´ Correlation of impairment, activity limitation, participation
restriction and goals stated in plan of care

Example: Conveying Medical
Necessity and Skilled Intervention

´ Patient tolerated treatment well. ´ Patient required verbal and
Patient completed shoulder manual cues to complete
exercises without issue. Continue shoulder flexion and abduction
with current plan to address exercises without substitution.
previously stated goals. Therapeutic exercise and right
shoulder mobilization resulted in
increased flexion from 90° to 110°
allowing the patient to reach
overhead and complete
activities of daily living. Patient still
unable to perform overhead
activities needed in performance
of job duties.

APTA (Member) Resources

´ APTA’s Center for Integrity in Practice:

´ Defensible Documentation Tips
´ Document Checklist
´ Tips for improving clinical documentation
´ Setting specific documentation considerations
´ Links to Medicare-related information
´ Payer Specific Websites

Electronic Medical Records/
Electronic Health Records

Abbreviations

EMR = Electronic Medical Record

• An electronic record of health-related information on an individual that can be created,
gathered, managed, and consulted by authorized clinicians and staff within one
healthcare organization

EHR = Electronic Health Record

• EHRs are real-time, patient-centered records that make information available instantly
and securely to authorized users. While an EHR does contain the medical and treatment
histories of patients, an EHR system is built to go beyond standard clinical data collected
in a provider’s office and can be inclusive of a broader view of a patient’s care

HIPAA = Health Insurance Portability and Accountability Act (of 1996)

• United States legislation that provides data privacy and security provisions for
safeguarding medical information.

1920s- 1950s Medical BACKGROUND

documentation
becomes more

common

1965: Medicare and Medicaid Act

1980s: Computers! Early 1990’s: Tracking of
services/medical
20th and 21st Century: Managed necessity
Care System
American
Recovery and
Reinvestment Act
of 2009 (ARRA)

Impact on quality, efficiency and cost

´ Benefits found:

´ Increased delivery of care based on guidelines (particularly in preventative
health)

´ Enhanced ability to monitor disease
´ Decreased medication errors

´ How technology is used and context for implementation impacts the
efficacy

´ Implementation within larger healthcare systems needs to be explored
further

Chaudhry B1, Wang J, Wu S, Maglione M, Mojica W, Roth E, Morton SC, Shekelle PG.
Systematic review: impact of health information technology on quality, efficiency, and costs of
medical care. Ann Intern Med. 2006 May 16;144(10):742-52. Epub 2006 Apr 11.

DEBATE …..(or maybe just a good
discussion)

Use of EHR…

PRO CON

´ Patient-provider relationship- ´ Patient-provider relationship-
Teams 1, 2, 3 Teams 8, 9

´ Interdisciplinary communication- ´ Interdisciplinary communication-
Teams 4, 5 Teams 10, 11

´ Patient outcomes- ´ Patient outcomes-
Teams 6, 7 Teams 12, 13, 14

Benefits and Barriers

´ Benefits ´ Barriers

´ Know more about patients ´ Financial
´ Better clinical decisions ´ Technological
´ Save $$ ´ Attitudes/Behaviors
´ Communication ´ Organizational change
´ Scheduling ´ Rapport building/distraction
´ Billing ´ Communication
´ Documentation (ease?)
´ Data management

Point of Care Documentation

´ Research shows gains in operational efficiency and use of clinical decision
support to impact patient management and outcomes when an EMR is
used while the PT is actually interacting with the patient, or at the “point of
care”

´ Barriers to communication with use of computer:

´ nonverbal behavior
´ computer navigation
´ mastery of skills
´ spatial organization

Point of care documentation

To do….or not to do?

Maintaining communication with
computer use

1) VERBALLY: maintaining conversation when looking at computer screen or
typing

2) VISUALLY: making eye contact with patient intermittently during computer
use

3) POSTURALLY: positioning head or torso toward the patient rather than
having their back to the patient during computer use

It’s a good thing!

´ Longitudinal study on impact of EMR use during encounter. Found increased:

´ Overall visit satisfaction
´ Satisfaction with the physician's level of familiarity
´ Satisfaction with communication about medical issues
´ Satisfaction with degree of comprehension with decisions made during visit

´ The use of computers resulted in the patient's perceptions that physicians were
more familiar with them as persons and with their medical history

Gadd CS, Penrod LE. Dichotomy Between Physicians' and Patients' Attitudes
Regarding EMR Use During Outpatient Encounters. Proceedings of the AIA
Symposium, 2000, pp. 275–279.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2243826/

SOAP Notes

LET’S REVIEW!

´S = Subjective ´Patient Says
´O = Objective
´A = Assessment ´P.T. Observes
´P = Plan and P.T. Analysis

Progression ´Plan of Care
and Progression
of Interventions

SUBJECTIVE

´ Tell the patient’s story
´HPI
´PMH
´Social History (family,
work, leisure, living
situation, etc.)
´Review of Systems
(patient-reported
symptoms)

“Patient reports difficulty sleeping on
his side due to shoulder pain.”

OBJECTIVE ´ Objective Data should be
READABLE
´ What you have examined:
´ Systems Review (hands on ´ Consider how you organize the
examination) information using
´ Cardiopulmonary
´ Musculoskeletal ´ Headings
´ Neuromuscular ´ Charts
´ Integumentary
´ Tests and Measures ´ Bullets
´ What you and/or patient did ´ Comparisons
´ Interventions
´Patient response to “L calcaneus Stage IV wound
treatments • LxWxD (3cm x 4cm x 1cm)
• No tunneling or exudates
• 50% granulation, 50% bone”

ASSESSMENT

´ How impairments effect function
´ Justification for services
´ Further testing (if applicable)
´ Documentation of inconsistencies
´ Do NOT repeat findings from S & O sections

´ Summarize!

´ Only portion where you share your impression/opinion concerning patient’s
presentation
“Patient presents with pain, decreased ROM and decreased
strength of the left knee. She will benefit from skilled physical
therapy to address deficits to allow patient to safely return to her
normal activities within her home environment including stair
climbing and ambulation.”

PLAN

´ Statements that:

´ Specify goals
´ Indicate predicted level of optimal improvement
´ Identify specific interventions to be used
´ Indicate proposed duration and frequency of interventions to reach goals and

outcomes

´ Section includes:

´ STGs
´ LTGs
´ Follow up services/Referrals
´ Prognosis

“Plan to trial spring AFO to assess effect on toe clearance during
swing phase of gait.”

Setting Patient Goals

´ Goals established during initial evaluation provide foundation on which
plan of care is directed

´ Goals are dynamic:

´ Progression (or lack of progression) and expected outcomes and discharge
planning are communicated through updates, changes and additions to initial
goals

´ To use goals to direct progression of PT services, goals should be:

´ Objective and measurable by reevaluation
´ Related to individual’s impairment, activity limitation, and participation restriction
´ Include anticipated timeframes
´ Written in functional terms and convey why PT is needed (not just a list of what

needs to be accomplished)

Goals = ABCD

´Audience

´Who will demonstrate skill

´Behavior

´What the person will do

´Condition

´What circumstances will assist the person to achieve
the goal (AD, level of assist, etc.)

´Degree

´How well or how often will they accomplish the goal



Components of well-written goals

´ Identification of the individual who is receiving therapy (could be
patient/client, caregiver, family)

´ Description of the movement or activity that individual will perform (i.e.
stand-pivot transfer from bed to chair)

´ A connection of the movement or activity to a specific function (i.e. swing
baseball bat)

´ Specific conditions in which the movement or activity will be performed
(i.e. with use of front-wheeled walker)

´ Factors for measuring performances (i.e. with minimal assistance)
´ The timeframe for achieving the goal

STGs & LTGs Should be CONNECTED

Short Term Goals Long Term Goals

´ Required to meet LTGs ´ Once LTGs met, patient should be
ready for d/c
´ Typically 1-2 weeks (inpatient); 2-6
weeks (outpatient) ´ Typically 3-4 weeks (inpatient); 6-
12 weeks (outpatient)
´ Addressed daily in hospital,
weekly in outpatient ´ Document progress towards these
goals regularly

How can we improve these goals?

´Patient will negotiate 4 steps with one
handrail and CGA to facilitate
improved access to her home.

´In 4 weeks, patient will negotiate 4
steps with one handrail and CGA to
facilitate improved access to her home.

´Patient will demonstrate increased R
knee flexion from 75° to 90° in one week.

´Patient will demonstrate increased R
knee flexion from 75° to 90° in one week
to improve ability to negotiate stairs.

´Patient will demonstrate proper use of RW
during gait training in two weeks to facilitate
increased safety with independent mobility
within the home.

´Patient will demonstrate proper use of RW
during gait training without verbal cues in
two weeks to facilitate increased safety with
independent mobility within the home.

´Patient will demonstrate proper
desensitization techniques on residual limb
with min verbal cues in order to decrease
phantom limb pain.

´In one week, patient will demonstrate
proper desensitization techniques on residual
limb with min verbal cues in order to
decrease phantom limb pain.

SOAP notes and the EMR

´ EMRs typically include templates and flowsheets for documenting services
´ Flowsheets are useful for:

´ Documenting specific interventions (i.e. exercises) and parameters of
interventions (i.e. reps, weight, etc.)

´ Efficiency

´ EMR templates and flowsheets may lack space for critical elements of
defensible documentation:

´ Response to treatment
´ Clinical reasoning/clinical decision making
´ Skilled care

TEAM APP: SOAP NOTE