Assessment/ Plan

Question 1

ICF stands for:

Answer 1

Internal classification of functioning, disability, and health system

Question 2

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

Answer 2

True

Question 3

What does the ICF model acknowledge?

Answer 3

The interaction of contextual factors

Question 4

_____ factors affect ability.

Answer 4

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

Question 5

What is a health condition?

Answer 5

Represents medial disorder or disease

Question 6

What is participation?

Answer 6

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

Question 7

What is a body function/ structure?

Answer 7

• Impairment
• ROM, Strength, Mobility, Joint Functions

Question 8

What are contextual factors?

Answer 8

• Environmental Factors
• Personal Factors

Question 9

What are Environmental factors?

Answer 9

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

Question 10

What are personal factors?

Answer 10

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

Question 11

The definition of disability is based on what?

Answer 11

Deviations from generally accepted population standards of people without health conditions

Question 12

What is another word for factors that promote positive health?

Answer 12

Facilitators

Question 13

What is another word for factors that impede health?

Answer 13

Barriers

Question 14

The assessment is where you do what?

Answer 14

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

Question 15

The assessment includes linking what 3 things?

Answer 15

• Impairments
• Activity limitations
• Participation restrictions

Question 16

What is clinical thinking?

Answer 16

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

Question 17

What is clinical reasoning?

Answer 17

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

Question 18

What is clinical judgement?

Answer 18

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)

Question 19

What 3 things does your assessment include?

Answer 19

• Evaluation
• Diagnosis
• Prognosis

Question 20

What is the key purpose of the evaluation?

Answer 20

Summarize the PTs clinical judgement

Question 21

Why is the evaluation mandatory in the SOAP note?

Answer 21

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

Question 22

What is the key purpose of the diagnosis?

Answer 22

To connect the dots

Question 23

What is a diagnostic statement?

Answer 23

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

Question 24

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

Answer 24

True

Question 25

What reflects the therapists thinking and justification of needed treatment?

Answer 25

Diagnostic statement

Question 26

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

Answer 26

True

Question 27

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

Answer 27

- Easily understood by other professionals - Easily understood by those making reimbursement decisions who may not have extensive medical knowledge

Question 28

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

Answer 28

- 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

Question 29

When is the prognosis completed?

Answer 29

After examination, evaluation, and diagnosis

Question 30

What does the prognosis predict?

Answer 30

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

Question 31

Where do you put your prognosis?

Answer 31

Can be apart of assessment or plan

Question 32

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

Answer 32

The complexity (low, medium, or high)

Question 33

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

Answer 33

- 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

Question 34

Your plan follows what?

Answer 34

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

Question 35

What are the two parts to the plan?

Answer 35

- 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)

Question 36

What are anticipated goals vs expected outcomes?

Answer 36

- 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

Question 37

What is an intervention?

Answer 37

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

Question 38

What are factors to consider with interventions?

Answer 38

- Allotted time for therapy - Patients current physical/ mental state - Patient support system

Question 39

What are examples of potential interventions?

Answer 39

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