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DOC for the PTA Chapter 11 Objective Data
Terms in this set (11)
includes any information that can be reproduced or observed by someone else with the same thing. when written it can explain the treatment to a non trained Physical Therapist, and whether the pt is benefitting from treatment.
What goes in the objective section?
-reader untrained in pT, insurance, lawyer, physician, committee member
2 kinds of readers that would be the audience reading the objective section?
1: The results of measurements and tests
2: A description of the pt's function
3: A description of the innervations provided
4: The PTA's objective observations of the pt
5: A record number of treatment sessions provided
6: Any patient education that was included in the treatment session for that day.
Six topics that are appropriate for the objective section of a soap note?
must include measurable, reproductible information so the efficacy of the Physical therapy can be determined. Includes initial evaluation where information relevant to the pt chief complaint and reason they are seeking care.
When writing objective data......
by reproducing the measurements and test completed in the initial evaluation, so they can be com-pared to previous session( E.g See distance walked in note dated in 8-2-17)
How are the results of tests and measurements documented?
-pt's functional skill
-quality of movement
- Level of assistance needed
-purpose of assistance
- pt. position
-measurements of surfaces
- environmental conditions
-cognitive status and any complicating factors
What information needs to be included when describing a pt's function?
-settings of the equipment
-duration/ frequency/ breaks of treatment
-special notes about pt. unique to that pt.
What information during the intervention needs to be reproducible?
Reporting what they did, and not reporting the pt's response to the treatment
Two most common mistakes students make when documenting objective data?
if a PTA/PT sees or feels anything that could be duplicated by another PTA or PT
What constitutes objective data?
could someone not trained in physical therapy do what I just described
What should a PTA/PT be asking themselves when documenting objective data?
No, because they should have enough information in the evaluation section to answer that question
Is it appropriate for a PT/PTA to ask what a pt. did with their prior PT/PTA
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