Acute Care Flashcards
1
Q
PT Roles
A
- Evaluate Functional Potential
- Implement POC
- Recommend next venue of care
- Recommend discharge needs
- Ensure pt’s safety with mobility
2
Q
Evaluation
A
Chart Review
Communication
HIstory
SOAP notes
3
Q
Chart Review
A
- Pt already evaluated by PT? OT?
- Physician’s Orders:
- PT order
- Precautions / restrictions:
- WB status
- ROM
- BP
- Bed rest
- Post-op
4
Q
Physician’s Orders: Scan Shortcut
A
Chart Section: Ultrasound / Doppler to R/O DVT CT/MRI due to altered mental status EKG Precautions/Restrictions Restraints Transfusion Surgery/Procedure Discharge
5
Q
Progress Notes
A
Chart section: communication b/w all disciplines
- MD's daily notes - Change in pt's status - POC - Instructions for PT
6
Q
H & P
A
Chart Section:
Hx of present illness Past medical Hx PLOF Social Hx Current meds Systems Review MD's prob list
7
Q
Laboratory Values
A
Chart Section
8
Q
Radiology / Nuclear Medicine Reports
A
Chart Section:
MRI
CT scan
X-rays
9
Q
Surgical Reports
A
Chart Section:
Surgeries performed
10
Q
Cardiac Testing
A
Chart Section:
EKG
Telemetry readings
11
Q
Interdisciplinary Care
A
Chart Section, info from:
Discharge planner
Clinical care mgmt
Pt education
12
Q
Special Diagnostics / Ancillary Services
A
Chart Section:
PT notes
13
Q
Medication Record
A
Chart Section:
List of meds
14
Q
Graphic Records
A
Chart Section:
Vital signs
Nutrition info
15
Q
Outcome Measures
A
- Kansas Univ Acute Care Functional Outcome
- TUG test
- Berg Balance Assessment
- Functional Reach Test
- Tinetti Performance Oriented Mobility Assessment
- Gait Speed
- Six Minute Walk
- Dyspnea Scale
- Rate of Perceived Exertion
- Timed Sit-to-Stand
