Duplicate of PTP FINAL

two types of codes: time-based codes, untimed codes

interpretation or impression of S & O; Summary of pt, diagnosis, problem list, factors that might influence treatment

each facility will have an employee who is responsible for implementing and enforcing this law

failure to comply with HIPAA also violates:

strength: N through all extremities; transfers w/c to and from mat c sliding board c min + 1 assist; AROM: WNL bilat LE

a hospital; short term patients due to illness, surgery, accident; discharge as soon as he/she medically stable; 3-5days

developed and enforced by the gov to protect its citizens and balance the society

practice laws, regulation, statutes and administratice code

current procedural terminology; categorized as physical medicine codes

rational reflection

previous therapy results, pertinent quotes, verbal history, present complants, goals, description of symptoms

documentations by exception should include:

comments by patients

our goal

must shred all materials with a paper shredder with a patients PHI/PMI

skilled verbiage with objective data

most think as laws, exists at national and state levels, written by legislators

purpose of documentation:

differences are appreciated

federal law examples include:

minimal standard that represents a kind of consensus or standards of behavior

information collected from the patient/ caregiver that is relevent to therapy

standards for what is right and wrong

relevant tests and measures; interventions provided; astute observations made with therapist's eyes, ears, hands

detailing comments consistent with chief complaints

what treatment will focus on the future

skilled documentation by CPT code with objective measurements of performance and education provided

specialized facility; all ages; provide intense therapy to improve pts ability to take care of him/herself; 1-2/6 weeks

practice consists of activities undertaken by indiv PT situated within a PTs unique body of knowledge where indiv is edu

physical therapy diagnosis:

assoc with SNF or extended care facility; generally elderly; resolution of recent decline; remained of lifespan

code of ethics, core values, standards of practice, APTA policies, APTA position statements, generic abilities

lack of cultural awareness and skills

culture is seen as a problem

jurisprudence is the theoretical study of law; seeks to explain understanding; sciency, study, and theory of law

the patient has the right to have an this for his PHI or PMI

specific treatment plan for the indentified problems of the patient

culture:

rules and regulations which govern practice, exits at national and state levels

angencies and individuals who handle PHI include: clerks, caregivers, PTs. nutritionists, lab personnel, etc

pt c/o pain L wrist; states hx of COPD since 2010; denies pain c cough; c/o pain L low back p sitting for ~ 10 min

practice established by states practice act governing the specific PT license, and rules of adopted pursuant to that act

potenial consequences for HIPAA violations:

nursing home; older patients with additional care; 1.5 hours a day; weeks to months

HIPAA:

personal values and beliefs, based on our culture and religon

develop when people are aware of what is right and wrong, become a standard that everyone must conform to

highest form of the law, exists at national and state levels

criminal stat prohibits transactions offering, soliciting, or accepting any type of gift or exchange for referrals etc

differences are recognized and accepted

any physician who provides any fed program cannot refer pt for specific health serves to any entity with financial inter

any data about the patient that would tend to identify the individual: name, hospital #, SSN, diagnosis, lab results etc

HIPAA regulations were designed to:

what objectives do privacy regulations accomplish for patients?

HPI, C/C, PMH, L/S, PLOF, MOI

components of skilled documentation by CPT code:

the ICF model:

person's residence; all ages; rehab to a functional level; several weeks or long periods of time

HIPAA applies to us in all settings - school, home, buses, as well as hospitals and clinics

based on precendence

gait: inep. c cx 1-% PWB R LE for 150 ft x 2; proprioception decrease in entire R UE

HIPAA ensures:

practice that is grounded in the professions unique body of knowledgel supp by educational prep, based on body of eviden

undistorted by emotion or personal bias; based on observable phenomena; systems review - general screening (HR, RR, BP)

clinical judement regarding why pt performed the way they did; obstacles are impacting clinical progress

the Federation state board of PT (FSBPT):

health info data from medical record that has been stripeed of all direct identifiers

as a student - you are authorized to photoduplicate and fax documents in the procress of working with patients PHI

this is CE's census or list of patients used by volunteers or operators to direct visitors

free standing clinical facility; short term musculoskel issues; restoration/rehab neuromusc/musculoskel; 1 -multi weeks

proceeding from or taking place in a person's mind rather than the external world; influenced by opinion

international standard for medical diagnostic classification; med diagnosis/referral diagnosis

the release of PHI to other CEs for TPO, treament, payment, or health care operations

critical analysis and evaluation or judgment of the status or quality of a particular condition, situation, or other sub

everyone is alike