CHAPTER 1 & 4 Flashcards
SOAP NOTE
SUBJECTIVE (FEELINGS FROM PATIENT); OBJECTIVE (DATA COLLECTED, WHAT WAS PERFORMED); ASSESSMENT (SKILLED ASSESSMENT/OBSERVATIONS, TIED TO OBJECTIVE); PLAN OF CARE (WHAT WILL HAPPEN NEXT)
WAIDET
WASH; ADDRESS; INFORM; DURATION; EXPLAIN; THANK YOU
ADVANCED CARE DIRECTIVES
LIVING WILL; ORGAN DONATION; POWER OF ATTORNEY; HEALTHCARE PROXY
PRINCIPLES OF DOCUMENTATION
EVAL/RE-EVAL/DISCHARGE VISIT/ENCOUNTER PATIENT'S CONSENT PLAN OF CARE RISKS/BENEFITS OF TREATMENT DIAGNOSIS & TREATMENT MD ORDER BARRIERS/SOLUTIONS
ELEMENTS OF INFORMED CONSENT PROCESS
STATUS & TREATMENT PLAN PATIENT QUESTIONS RISKS, COMPLICATIONS, PRECAUTIONS PROGNOSIS & OUTCOMES DOCUMENTATION
PRINCIPLES OF DOCUMENTATION
EVERY VISIT; REGULATORY REQUIREMENTS; IDENTIFICATION, REFERRAL SOURCE, SIGN AND DATE;
SPECIFIC, CONCISE & CLARIFYING; FUNCTIONAL; SIGNIFICANT; CONTINUATION, INFORMED CONSENT
PROMPT & LEGIBLE; APPROVED ABBREVIATIONS; NO BLANK LINES OR SPACES; MENTALLY OR MANUALLY PLAN THE NOTE
EVIDENCE BASED PRACTICE (EBP)
USE OF DISABLEMENT MODELS
VALUE-DRIVEN PATIENT CARE
CLINICAL OUTCOME MEASURES
PROFESSIONAL COMMUNICATION
VERBAL; NONVERBAL; AUDIOVISUAL AIDS; WRITTEN
WHY USE PROPER BODY MECHANICS
CONSERVES ENERGY; REDUCES RISK OF INJURY; LEADS SAFE & PROPER SPINE MOVEMENTS
CORE OF BODY
INVOLVES TORSO, SPINE, ABDOMINALS & PELVIC FLOOR; PROVIDES STRENGTH, PROPER MOVEMENT
PRINCIPLES OF PROPER BODY MECHANICS
- SIZE UP LOAD
- MENTALLY & PHYSICALLY PREPARE
- INCREASE YOUR BOS
- POSITION YOURSELF CLOSE TO BOJECT TO BE MOVED
- POSITION YOUR COG CLOSE TO OBJECT’S COG
- TIGHTEN YOUR CORE MUSCLES
- ROLL, PUSH, PULL OR SLIDE THE OBJECT TO BE MOVED
- LOOK STRAIGHT AHEAD
- TAKE YOUR TIME, MOVE SMOOTHLY
- AVOID TRUNK FLEXION WITH ROTATION
CAUSES OF POTENTIAL INJURIES
LUMBAR SPINE MOST VULNERABLE; MEANS OF INJURY (LIFTING IMPROPERLY, REPETITIVELY); PAIN SENSITIVE STRUCTURES (CUMULATIVE EPISODES OF MICROTRAUMA)
POSITION FOR LIFTING
NEUTRALPOSITION OF LORDOSIS OF THE LUMBAR SPINE; PARTIAL TO FULL FLEXION OF THE HIPS & KNEES; CONTRACTION OF CORE STABILIZING MUSCLES; NO ROTATION
5 MAIN LIFTS
DEEP SQUAT LIFT; POWER LIFT; STRAIGHT LEG LIFT (OUT OF A TRUNK); ONE-LEG STANCE LIFT (GOLFER’S LIFT); HALF KNEELING LIFT
ELECTRODIAGNOSTIC TESTS
THE USE OF AN ELECTRICAL CURRENT TO ASSIST WITH THE DIAGNOSIS OF A PATIENT’S CONDITION