Assessment/ Plan Flashcards
ICF stands for:
Internal classification of functioning, disability, and health system
T/F: the ICF model was designed to establish a framework for a comprehensive health measurement the focuses on ability.
True
What does the ICF model acknowledge?
The interaction of contextual factors
_____ factors affect ability.
All
- Ability to function is presumably affected by all surrounding factors
What is a health condition?
Represents medial disorder or disease
What is participation?
- Involvement in a life situation
- What are the restrictions or limitations
What is a body function/ structure?
- Impairment
- ROM, Strength, Mobility, Joint Functions
What are contextual factors?
- Environmental Factors
- Personal Factors
What are Environmental factors?
- Physical environment
- Resources
- Availability of items
- What can impede or support improvement
What are personal factors?
- Factors specific to that patient
- Age
- Gender
- Past/ current experiences
- Education level
- Social background
- Support system
The definition of disability is based on what?
Deviations from generally accepted population standards of people without health conditions
What is another word for factors that promote positive health?
Facilitators
What is another word for factors that impede health?
Barriers
The assessment is where you do what?
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
The assessment includes linking what 3 things?
- Impairments
- Activity limitations
- Participation restrictions
What is clinical thinking?
Analyzing knowledge based on evidence and science (knowledge of the subject)
What is clinical reasoning?
Application of critical thinking with clinical setting (the relevance of the knowledge and evidence)
What is clinical judgement?
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)
What 3 things does your assessment include?
- Evaluation
- Diagnosis
- Prognosis
What is the key purpose of the evaluation?
Summarize the PTs clinical judgement
Why is the evaluation mandatory in the SOAP note?
- Provides accurate and brief summary
- Justifies continued PT intervention
- Assists in location of impairments and restrictions
What is the key purpose of the diagnosis?
To connect the dots
What is a diagnostic statement?
- Describes the relationship between the examination findings
- Connects patients limitations and restrictions to impairments and medical diagnosis
T/F: A diagnostic statement usually consists of more than one sentence.
True
What reflects the therapists thinking and justification of needed treatment?
Diagnostic statement
T/F: A diagnosis will include a functional deficit.
True
The diagnosis and statement should be stated so that they are:
- Easily understood by other professionals
- Easily understood by those making reimbursement decisions who may not have extensive medical knowledge
What is the difference between a medical diagnosis and a therapy diagnosis?
- 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
When is the prognosis completed?
After examination, evaluation, and diagnosis
What does the prognosis predict?
Level of improvement in activities and participation and amount of time needed
Where do you put your prognosis?
Can be apart of assessment or plan
You prognosis will state what about the level of your evaluation?
The complexity (low, medium, or high)
What happens if you make a mistake in a handwritten SOAP note?
- 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
Your plan follows what?
Your examination (subjective + objective) and your evaluation (assessment)
What are the two parts to the plan?
- 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)
What are anticipated goals vs expected outcomes?
- 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
What is an intervention?
Form of treatment that a patient will receive during the entirety of skilled therapy
What are factors to consider with interventions?
- Allotted time for therapy
- Patients current physical/ mental state
- Patient support system
What are examples of potential interventions?
- Therapeutic exercise
- Education
- Joint Mobilizations
- PNF
- Manual Therapy
- Functional Activities
- Balance
- Gait
- Modalities
