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Experiential Learning Mid Term > Assessment/ Plan > Flashcards

Assessment/ Plan Flashcards

1
Q

ICF stands for:

A

Internal classification of functioning, disability, and health system

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2
Q

T/F: the ICF model was designed to establish a framework for a comprehensive health measurement the focuses on ability.

A

True

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3
Q

What does the ICF model acknowledge?

A

The interaction of contextual factors

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4
Q

_____ factors affect ability.

A

All
- Ability to function is presumably affected by all surrounding factors

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5
Q

What is a health condition?

A

Represents medial disorder or disease

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6
Q

What is participation?

A
  • Involvement in a life situation
  • What are the restrictions or limitations
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7
Q

What is a body function/ structure?

A
  • Impairment
  • ROM, Strength, Mobility, Joint Functions
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8
Q

What are contextual factors?

A
  • Environmental Factors
  • Personal Factors
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9
Q

What are Environmental factors?

A
  • Physical environment
  • Resources
  • Availability of items
  • What can impede or support improvement
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10
Q

What are personal factors?

A
  • Factors specific to that patient
  • Age
  • Gender
  • Past/ current experiences
  • Education level
  • Social background
  • Support system
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11
Q

The definition of disability is based on what?

A

Deviations from generally accepted population standards of people without health conditions

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12
Q

What is another word for factors that promote positive health?

A

Facilitators

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13
Q

What is another word for factors that impede health?

A

Barriers

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14
Q

The assessment is where you do what?

A

Add all the examination together (S+O)
- Problem: diagnosis
- Subjective: information verbally provided by patient or other source
- Objective: measurable data gathered by the PT regarding chief complaint

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15
Q

The assessment includes linking what 3 things?

A
  • Impairments
  • Activity limitations
  • Participation restrictions
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16
Q

What is clinical thinking?

A

Analyzing knowledge based on evidence and science (knowledge of the subject)

17
Q

What is clinical reasoning?

A

Application of critical thinking with clinical setting (the relevance of the knowledge and evidence)

18
Q

What is clinical judgement?

A

Reflecting on clinical thinking and clinical reasoning in determining assessment of patients problem (conclusion about patients health problems and what action is or is not needed)

19
Q

What 3 things does your assessment include?

A
  • Evaluation
  • Diagnosis
  • Prognosis
20
Q

What is the key purpose of the evaluation?

A

Summarize the PTs clinical judgement

21
Q

Why is the evaluation mandatory in the SOAP note?

A
  • Provides accurate and brief summary
  • Justifies continued PT intervention
  • Assists in location of impairments and restrictions
22
Q

What is the key purpose of the diagnosis?

A

To connect the dots

23
Q

What is a diagnostic statement?

A
  • Describes the relationship between the examination findings
  • Connects patients limitations and restrictions to impairments and medical diagnosis
24
Q

T/F: A diagnostic statement usually consists of more than one sentence.

A

True

25
Q

What reflects the therapists thinking and justification of needed treatment?

A

Diagnostic statement

26
Q

T/F: A diagnosis will include a functional deficit.

A

True

27
Q

The diagnosis and statement should be stated so that they are:

A
  • Easily understood by other professionals
  • Easily understood by those making reimbursement decisions who may not have extensive medical knowledge
28
Q

What is the difference between a medical diagnosis and a therapy diagnosis?

A
  • Medical diagnosis: uses categories based on signs and symptoms (ICD-10 codes for billing)
  • Therapy diagnosis: includes diagnostic statement describing relationship between medical diagnosis and affect on patients function
29
Q

When is the prognosis completed?

A

After examination, evaluation, and diagnosis

30
Q

What does the prognosis predict?

A

Level of improvement in activities and participation and amount of time needed

31
Q

Where do you put your prognosis?

A

Can be apart of assessment or plan

32
Q

You prognosis will state what about the level of your evaluation?

A

The complexity (low, medium, or high)

33
Q

What happens if you make a mistake in a handwritten SOAP note?

A
  • PPT answer: Place one line through the mistake and place the therapist or PT student initials above with circle
  • We were told one line with name, date, and time in class
34
Q

Your plan follows what?

A

Your examination (subjective + objective) and your evaluation (assessment)

35
Q

What are the two parts to the plan?

A
  • Document planned interventions
  • Document expected outcomes and anticipated goals (remember goals may be present at the end of the assessment or have their own tab in the EMR)
36
Q

What are anticipated goals vs expected outcomes?

A
  • Anticipated goals: short term goals that can be stepping stones to achieve expected outcomes
  • Expected outcomes: long term goals that help with final functional status and are found at the end of skilled therapy intervention
37
Q

What is an intervention?

A

Form of treatment that a patient will receive during the entirety of skilled therapy

38
Q

What are factors to consider with interventions?

A
  • Allotted time for therapy
  • Patients current physical/ mental state
  • Patient support system
39
Q

What are examples of potential interventions?

A
  • Therapeutic exercise
  • Education
  • Joint Mobilizations
  • PNF
  • Manual Therapy
  • Functional Activities
  • Balance
  • Gait
  • Modalities

Experiential Learning Mid Term (6 decks)

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