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  1. VIDEO-BASED (VB) MEDICAL DOCUMENTATION:  You will need to be on-line to utilize this resource.

The following videos provide short excerpts from PT treatments. You will create a SOAP note based on the vignette you view.

VB Activity 1:

  1. https://libraries.psu.edu/
  2. Select “Databases”
  3. Select “I”
  4. Select “ICE (International Clinical Educators) Learning Center “
  5. Enter “Acute Care” in the Search Bar
  6. Select: “Total Hip Replacement, Part 2: Bedside Exercises in Acute Care”

VB Activity 2: Follow above procedure

Select: “Total Hip Replacement, Part 3: Preparing to Stand in Acute Care”

VB Activity 3: Follow above procedure

Select: “Total Hip Replacement, Part 4: Ambulation in Acute Care”

2. Additional Resources: For further enrichment in the area of medical documentation, the following links are provided.  You may find them very useful as you progress through the PTA Program and your clinical experiences.

  1. The following link will take you to the APTA’s: GUIDELINES: PHYSICAL THERAPY DOCUMENTATION OF PATIENT/CLIENT MANAGEMENT.           It details and describes the various documents we use to record our patient’s progress and status.

http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Practice/DocumentationPatientClientManagement.pdf

2.  The following link (to the website of: WebPT; a site that you will find very useful as a student-therapist and therapist, will bring you to a very reader-friendly document regarding defensible documentation. You will benefit greatly from reading this article.

https://www.webpt.com/blog/post/what-defensible-documentation

3. The following link will bring you to another APTA-related site. This will provide you with a review of documentation as well as offer other links if you choose to go deeper.

https://integrity.apta.org/Documentation/

License

Physical Therapy Assistant Medical Documentation Copyright © by Wade Shumaker; jmm49; and djd139. All Rights Reserved.

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