Purpose: To instruct on documenting a Therapy Evaluation in Pointcare.
NOTE - Reference table is below the video to search for key components of evaluation if 'refresher' is needed to assist in system navigation or quality of documentation.
REFERENCE TABLE
Subject | Time |
Start appointment | 1:30 |
Mileage/Drive Time | 2:40 |
Vital Signs & Measures | 3:20 |
View Parameters | 4:45 |
Physical Assessment | 5:15 |
Within Physical Assessment - Integumentary | 9:20 |
Within Physical Assessment - Functional | 10:10 |
Within Physical Assessment – Functional Tests and Measures | 11:25 |
Within Physical Assessment – Pain | 13:10 |
Within Physical Assessment – Care Coordination | 17:30 |
Within Physical Assessment – Changes Need to Plan of Care | 18:30 |
Patient Goals | 19:15 |
Diagnoses | 20:00 |
Pathways | 22:30 |
Interventions/Goals | 23:50 |
Therapy Goals/Status | 26:50 |
New Order | 31:00 |
Add Calendar (within new order) – where you establish frequency & duration | 38:00 |
Therapy Assess/Plan | 42:10 |
Sign Out (always choose either ‘complete’ or ‘incomplete’ at end of every visit to prompt patient signature) | 45:10 |
Adding Verbal Order to Evaluation (after visit) | 46:30 |
Narrative | 47:50 |
Sync | 51:35 |