A patient has been in the physical therapy department for the past 20 minutes and has received electrical stimulation to the upper trapezius bilaterally while lying prone on a treatment table. There were hot packs placed on top of the electrodes, and the patient felt a mild but comfortable tingling sensation during the application of the electrical stimulation. She had initially complained of pain and muscle tightness in her neck that limited her mobility in cervical rotation. After removing the electrodes and hot packs, she now reports that her discomfort is a "2/10 from the 9/10 that it was" and she can "freely move her neck." Where and how should the treatment intervention be documented?
A)Patient comments should be placed in quotes in black ink in the patient's chart.
B)The intervention should be documented in a flow sheet in the patient's chart and then signed by the treating therapist.
C)Treatment interventions or "what was done" should be documented in the objective portion of the note and the outcome should be documented in the assessment portion of the note.
D)"Patient tolerated treatment well" should be documented in the assessment portion of the treatment notes.

Question

Quizplus · Accepted Answer

Treatment interventions, including what was done during the session (e.g., electrical stimulation to the upper trapezius bilaterally with hot packs), are documented in the objective section of the patient's notes. The outcomes of the intervention, such as the patient's reported decrease in pain and increased mobility, are documented in the assessment section. This structure follows the SOAP (Subjective, Objective, Assessment, Plan) format commonly used in medical and therapy documentation.

A Patient Has Been in the Physical Therapy Department for the Past