Chapter 2 Communication and Patient/Client Management Process

Learning Outcomes

Upon completion of this chapter, you will be able to:

1. Describe the elements of the Patient/Client Management process presented in the Guide

to Physical Therapist Practice (Guide).

2. Describe the purposes of an initial interview with the patient.

3. Describe the two styles of questions, and when they are used, in an interview.

4. List and provide examples of the content included in an initial patient interview.

5. List the purposes of documentation in the healthcare system.

6. Discuss the requirements of adequate documentation.

7. Describe two formats of medical records: discipline-specific medical record and problem-

oriented medical record.

8. Describe two formats of documentation within the medical record: SOAP note format

and Guide note format.

9. Discuss resources related to Medicare requirements for documentation.

10. Write examples of patient goals, using appropriate criteria for content and format.

11. Describe the purposes of medical record audits.

12. List the information necessary to perform an appropriate medical records audit.

13. List the information provided by an appropriate medical records audit.

14. Describe the purposes and characteristics of instructions and verbal cues.

Key Terms

Active listening

Audits

Chart review

Closed-ended questions

Diagnosis

Discharge plan

Documentation

ECHOWS

Effective communication

Episode of physical therapy

Evaluation

Examination

Explanatory Model

Feedback

Goals (long term and short term)

Instructions

Intake form

Interventions

Open-ended questions

Outcomes

Patient/client management

Plan of care

Preferred practice patterns

Prognosis

Red Flag

Signs

SOAP notes

Subjective

Objective

Assessment

Plan

Symptoms

Systems review

Tests and measures

Verbal cues

Yellow Flag

Lecture Outline

1. Introduction

a. Review Learning Outcomes

b. Effective communication essential to quality care

c. PT patient/client management process assists to ensure quality care

2. Aspects of Effective Communication

a. Culturally sensitive

b. Active listening

i. Be “present”

ii. Make eye contact and address person by preferred name

iii. Body language

iv. Stay focused on one topic

v. Summarize your discussion

vi. Ascertain that patient understands your message

c. Instructions and verbal cues: purposes and characteristics

d. Feedback: purposes and characteristics

3. Physical Therapist Patient/Client Management

a. Process by which physical therapists generate and implement a POC

b. Examination

c. Evaluation

d. Diagnosis

e. Prognosis

f. Intervention

g. Outcomes

h. Preferred Practice Patterns

i. Musculoskeletal

ii. Neuromuscular

iii. Cardiovascular/pulmonary

iv. Integumentary

4. Physical Therapy Patient/Client Management Process

a. Examination

i. Chart review

ii. Intake forms

iii. Patient interview

1. Types of information to be obtained

2. Types of questions and their purposes

a. Open-ended questions

b. Close-ended questions

3. Explanatory Model

4. ESCHOWS

5. Summarize

iv. Systems review

v. Tests and measures

b. Evaluation

i. Review all data collected to generate diagnosis, prognosis

c. Diagnosis

i. Differential diagnosis

ii. PT diagnosis based on Preferred Practice Patterns

d. Prognosis

i. Optimal level of improvement

ii. Time to achieve

iii. Plan of Care (POC)—outline of physical therapy management

1. Goals

a. ABCDFT format

b. Long-term goals

c. Short-term goals

e. Interventions

i. Care provided

ii. Discharge plan

f. Outcomes

g. Documentation

i. Essential component of management

ii. Purposes

iii. Requirements for adequate documentation

1. Timely, accurate, appropriate, clear, precise, concise, organized, complete, and

legible

2. Date of service and signed

3. Line through error with date and initials

4. APTA has recourses to assist with documentation

iv. Formats of Medical Records

1. Source-oriented medical records

2. Problem-oriented medical record

v. Formats of notes

1. Headings used to organize information

2. SOAP note format

3. Patient/Client management process note format

vi. Medicare Guidelines

1. Insurance companies often follow Medicare/Medicaid guidelines

2. Government resources for documentation guidelines

3. Guidelines are by setting in which care is provided

vii. Audit of Patient Care

1. Reviews of documentation to examine efficiency and efficiency of patient care

outcomes

2. Information obtained from an audit of PT documentation

Answers to Chapter Review Questions

1. What are the elements of the Patient/Client Management Process presented in the Guide to

Physical Therapist Practice (Guide)? Describe each. The five elements of physical therapy

patient/client management are (1) examination, (2) evaluation, (3) diagnosis, (4) prognosis,

and (5) intervention. Examination is the process of generating a patient/client history,

reviewing all physiologic systems, and applying tests and measures. Some of the tests and

measures selected by a physical therapist may be performed by a physical therapist assistant

under the direction and supervision of a physical therapist. Evaluation is the process

whereby physical therapists use examination data, professional knowledge, and clinical

judgment to identify impairments and functional limitations and to generate diagnoses,

prognoses, and a plan of care. Diagnosis is assignment of a label that states the

categorization or classification of problems identified, and selected from the practice pattern

or diagnostic category that most closely describes a patient’s impairments and functional

limitations as presented in the Guide. A physical therapist’s diagnosis is related to

impairments and functional limitations. Diagnosis directs the development of prognosis, plan

of care, and selection of interventions. When a physical therapist cannot place a patient in a

diagnostic category, the patient’s active pathology is not within the scope of physical therapy

practice. In such cases, physical therapists refer patients to appropriate healthcare

practitioners. Prognosis is the determination of optimal level of improvement and time

necessary to achieve projected outcomes. A plan of care is a statement that specifies

outcomes, interventions to be provided to achieve the stated outcomes, and a timeline for

reaching the stated outcomes. An intervention includes treatment, communication,

education, and planning. Some aspects of treatment, communication, and education may be

performed by a physical therapist assistant under the direction and supervision of a physical

therapist.

2. What types of information are obtained during initial patient interviews?

a. Past medical history: example history of high blood pressure

b. Present complaint: example neck pain

c. Functional ability: example able to perform all ADLs

d. Functional problems: example pain when performing ADLS

e. Goals: example be pain free

3. What are open-ended and closed-ended questions? Provide examples for use during patient

interviews.

Open-ended questions are questions that permit the person to direct the answer as they

chose providing either vague or specific information. Examples of open-ended questions are:

“What are the problems you are having?” or “Tell me about your injury.” Closed-ended

questions direct the person to give a specific answer while allowing the person to determine

the direction of the response. An example of a closed-ended question is: “Have you ever had

this pain before?” Closed-ended questions are often answered with a single word or a brief

phrase, such as “Yes,” “No,” or “Yes, once or twice before.”

4. What are the purposes for open-ended and closed-ended questions used in patient interviews?

Open-ended questions allow a patient to tell his/her story in his/her own words. Closed-

ended questions are used to obtain or confirm specific information.

5. What are the purposes of documentation in the healthcare system?

a. Communication

b. History of what has occurred

c. Coordination of patient care

d. Legal document

6. What are the requirements of adequate documentation of healthcare provider–patient

interactions?

a. Timely, accurate, appropriate, clear, precise, concise, organized, complete, and

legible.

b. Date of services provided

c. Signed by person providing services with professional designation

d. Dated

e. Errors properly correctly

f. Support the need for services

g. Support the skilled services provided

h. Interventions with specifics

i. Appropriate use of abbreviations

j. Patient responses to management

7. What are the similarities and differences between the two formats of medical records:

discipline-specific medical record and problem-oriented medical record?

a. Similarities

i. Record of patient needs and services provided

ii. Need to meet requirements for adequate documentation

b. Differences

i. Problem-Oriented Medical Record organized around each patient problem

ii. Source-Oriented Medical Record organized by service that is providing care

8. What are the similarities and differences between the two formats of documentation within

the medical record: SOAP note format and Guide note format?

a. Similarities

i. Record of patient problems and services provided

ii. Must meet requirements for adequate documentation

iii. Address only the appropriate parts of the format in a specific note

b. Differences

i. SOAP format note divided into four sections: SOAP. Information presented within

each section may be organized by subheadings.

ii. Guide format note divided into the six sections of the Patient/Client Management

Process with subheadings within each section.

9. What resources are available to assist with meeting Medicare requirements for

documentation?

a. APTA website has information

b. Government websites have information

10. How do medial records audits contribute to quality patient care?

a. By reviewing documentation, a department can determine if documentation is

adequate and if patients are making the appropriate progress in a timely manner.

Corrective action plans can be developed in response to audit results when

appropriate.

11. What are the purposes and characteristics of instructions, verbal cues, and feedback?

a. Communication with a patient

b. Instructions inform a patient of what is to be performed and provided information as

part of the teaching process.

i. Instructions must be simple, informative, and in a language and terms a patient

can understand.

c. Verbal cues direct the performance of an activity.

i. Verbal cues are clear, brief, specific, properly timed, and spoken in an

appropriate tone and volume.

d. Feedback is given to assist a patient to correctly perform an activity and to provide

encouragement.

i. Feedback is brief and focused

Lab Activities: Suggested Activities

1. Write examples of patient goals, using appropriate format (ABCDFT) and criteria.

2. Create lists of the information that should be collected during a medical record audit of

physical therapists’ patient notes.

3. In groups of three practice interviewing using the ECHOWS tool; rotate roles so each person

is interviewer, interviewee, and observer completing the ECHOWS tool and noting questions

used.

a. Review with the interviewer the questions used, noting appropriate use of open-ended

and close-ended questions.

b. Review the ECHOWS tool and discuss results.

c. Develop an action plan to improve interview skills.

4. Using the Information about Mr. Doe, write two notes one in SOAP format and one in

Patient/Client Management format. Create new goals using the ABCDFT format.

5. In the following table, indicate the appropriate section of SOAP notes and Patient/Client

Notes for each of the statements in the table.

SOAP Note Patient/Client Note Patient Information

O Tests and Measures ROM R shoulder flexion 0–85

S History The family reports that the patient

fell during the night

P Plan of Care Patient is to receive treatment

2x/week for 3 weeks.

A Evaluation The patient can ambulate with a

small base quad cane on all surfaces

for 150 ft without fatigue in 4

weeks.

A Evaluation Pain was 5/10 following

intervention with TENS.

A Evaluation Patient’s pain level decreased

following interventions.

O Tests and Measures Patient step over step using the hand

rail 4 times.

A Evaluation The patient’s ability to assume

standing from sitting is impaired

because of weakness of bilateral

quadriceps muscles.

Answers to Chapter Case Studies

1. Mr. Jimenez, a 67-year-old man, is 2 days post left total knee replacement. He is to be

discharged to the hospital’s skilled nursing facility in 2 days for additional physical therapy.

Mr. Jimenez’s goal is to be a community ambulator without any ambulatory assistive device.

The physician has indicated that when Mr. Jimenez has 90 degrees of left knee flexion, good

strength of left knee flexors and extensors, and can ambulate 200 feet x 4, he can be

discharged to his home. Mr. Jimenez reports pain of 4/10 about the incision. The

approximately 5-inch incision is anterior over the left knee in a proximal distal direction.

Some clear discharge is noted at the end of the incision. The incision is closed with staples.

The circumference of the left knee at 2 inches about the tibial tuberosity is ¾ inch greater

than on the right knee.

Eduardo Jimenez SSN: 123-45-6789

415 Main St. DOB: 05/08/45

Any City, USA Record: 444-3-45-897

Phone (555) 212-2222

a. Using this information, identify and list information that is covered by HIPAA

regulations.

i. Eduardo Jimenez SSN: 123-45-6789

ii. 415 Main St. DOB: 05/08/45

iii. Any City, USA Record: 444-3-45-897

iv. Phone (555) 212-2222

v. Diagnosis

vi. Age

b. Organize the narrative note into a SOAP note format and a Patient/Client Management note

format.

Note very little information is provided in the narrative about Mr. Jimenez.

i. SOAP note

Eduardo Jimenez DOB: 05/08/45 Record: 444-3-45-897

Medical diagnosis: Left total knee replacement 2 days prior

S: Goal is to be a community ambulator without any ambulatory assistive device.

Pain about incision is 4/10.

O: The approximately 5-inch incision is anterior over the left knee in a proximal

distal direction. Some clear discharge is noted at the end of the end of the incision.

The incision is closed with staples. The circumference of the left knee at 2 inches

about the tibial tuberosity is ¾ inch greater than on the right knee. He reports

minimal pain about the incision.

A. Mr. Jimenez is a 67-year-old male s/p 2 days left total knee replacement. Incision

is healing. Some swelling is present. Pain is minimal.

P. Mr. Jimenez is to be discharged to skilled nursing facility in 2 days. The physician

has indicated that when Mr. Jimenez has 90 degrees of left knee flexion, good

strength of left knee flexors and extensors, and can ambulate 200 feet x 4, he can be

discharged to his home.

Mary Sunshine, PT, DPT

00/00/0000

ii. Guide note

Eduardo Jimenez DOB: 05/08/45 Record: 444-3-45-897

Examination:

Surgical History: 2 days s/p left total knee replacement

Systems Review: Incision anterior left knee

Tests and Measures: Pain about incision is 4/10. The approximately 5-inch incision is

anterior over the left knee in a proximal distal direction. Some clear discharge is

noted at the end of the end of the incision. The incision is closed with staples. The

circumference of the left knee at 2 inches about the tibial tuberosity is ¾ inch greater

than on the right knee.

Evaluation: Mr. Jimenez is a 67-year-old male s/p 2 days left total knee replacement.

Incision is healing. Some swelling is present. Pain is minimal.

Plan of Care: Mr. Jimenez is to be discharged to skilled nursing facility in 2 days.

The physician has indicated that when Mr. Jimenez has 90 degrees of left knee

flexion, good strength of left knee flexors and extensors, and can ambulate 200 feet x

4, he can be discharged to his home.

Mary Sunshine, PT, DPT

00/00/0000

c. Write two short-term goals based on Mr. Jimenez’s long-term goal.

Examples of appropriate goals

i. Mr. Jimenez will have 90 degrees of left knee flexion in one week.

ii. Mr. Jimenez will have good strength of left knee flexors and extensors in 8 weeks.

iii. Mr. Jimenez can ambulate 200 ft x 4 independently with a walker in 2 weeks.

2. All physical therapists/assistants in the department are contributing to the development of a

documentation checklist to ensure quality documentation of patient care. As a member of the

department, develop a list of items to be included on the documentation checklist with

justification for inclusion of each item.

Required for adequate documentation:

a. Timely, accurate, appropriate, clear, precise, concise, organized, complete, and legible.

b. Date of services provided

c. Signed by person providing services with professional designation

d. Dated

e. Errors properly correctly

f. Support the skilled services provided

g. Support the need for services

h. Interventions with specifics

i. Appropriate use of abbreviations

j. Patient responses to management

k. Specific information to be included: See Figure 2-5 Physical Therapist Patient/Client

Management Note Format: Headings and Subheadings