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 problemoriented 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. Closedended 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.
Any City, USA
DOB: 05/08/45
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.
iii.
Any City, USA
iv.
Phone (555) 212-2222
v.
Diagnosis
vi.
Age
DOB: 05/08/45
Record: 444-3-45-897
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