Provided in the examples below are phrasing/words that are commonly seen as buzz words to not use in documentation.  Change the underlined phrase/word to a more acceptable and skilled form.            A: Pt has some biceps weakness.

Your patient is diabetic and has peripheral neuropathy. As a result they have LE weakness, requires assistance for shower transfers, and is unable to walk long distances.  The patient’s daughter does the grocery shopping.  According to the ICF, the patient’s participation restriction is:

Organize the following information so that it is clear, concise, and suitable for entry into the medical record.  Be sure to include which part of the SOAP note it belongs.  The patient walked with the physical therapist assistant at his side (but not touching him) for 100 feet, twice; vital signs before exercise were blood pressure 125/85 in L UE, 15 for respirations, and 77 for heart rate; vital signs after were 135/85 for blood pressure taken in the L UE, 17 for respirations, and 87 for heart rate; the patient performed ankle pumping, elbow flexion, shoulder flexion and knee extension bilaterally for 10 repetitions each while sitting in a bedside chair.

The ICF disablement model:

Use the following chart regarding the Medicare 8 Minute Rule to determine the appropriate charges for the patient treatments listed below. Timed Codes                                                                          8 Minute Rule Chart 97035 – Ultrasound                                                               0 to < 8 minutes = no charge 97140 – Manual Therapy                                                    8 to 22 minutes = 1 unit 97110 – Therapeutic Exercise                                          23 to 37 minutes = 2 units                97112 – Neuromuscular Reeducation                         38 to 52 minutes = 3 units 97116 – Gait Training                                                              53 to 67 minutes = 4 units 97530 – Therapeutic Activity   Pt is s/p ORIF L hip. TTWB L LE. You are treating this patient in a skilled nursing facility.  You documented that you provided 10 minutes of therapeutic exercise for LE ROM and strengthening, 10 minutes of gait training with RW, TTWB L LE, and 10 minutes of therapeutic activity for transfer training and standing tolerance, TTWB L LE.  Document your time and charge for the treatment. Total treatment time: Treatment minutes: Charges:

A really conscientious health provider can eliminate his or her own prejudices or negative assumptions about certain types of patients.

Continuing to pay individuals who have proven themselves to be less than competent in their job performance is actually rewarding poor work quality.

What should the PTA know when observing and interpreting a patient’s nonverbal communication? 

An 84-yr. old cognitively impaired person transferred from a nursing home to an acute care facility (hospital).  The patient has history of dementia. The pt has become increasingly agitated and combative in the last few days and requires minimal assistance for functional mobility; this is unusual for the patient. The patient is typically able to walk independently with a walker at the nursing home.  Laboratory test reveals a urinary tract infection. The patient is beginning to receive antibiotics for the infection. Communication with patients is an integral skill for a health care worker. The following is an example of ineffective communication with the above patient :

Generally, the higher your insurance premium, the lower your deductibles and out of pocket expenses.