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Patient Management > Chart Review, ICF, Patient Centered Interview > Flashcards

Chart Review, ICF, Patient Centered Interview Flashcards

1
Q

What does the ICF model do?

A

framework for communicating and studying impact of disease on ability to interact w/ environment

common language to delineate consequences of disease and injury

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2
Q

WHO on ICF

A
  • dynamic interaction between health conditions and personal/environ factors
  • looks beyond mortality/disease- focuses on “how ppl live w/conditinos”
  • considers health from bio, individ, and societal perspec”
  • model of choice in research, health prac education, and health care systems
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3
Q

What does ICF emphasize

A

components of health over consequences of disease

Participation over disability
Role in society
Environ and personal factors contributing to overal “health”
Considers WHOLE person

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4
Q

3 levels of human function in ICF

A

Function at level of BODY PARTS (physio)
Function at level of WHOLE PERSON
Function of whole person in their COMPLETE ENVIRON

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5
Q

ICF Domains:

BODY STRUC and FUNCTION

A

anatomical parts of body
physio functions of body systems
IMPAIRMENTS are the problems (temp or permanent)

ex: balance, pain, weakness, muscle tone, contractures, HR/BP, ROM, endurance, sensation, etc.

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6
Q

ICF Domains:

ACTIVITY

A

execution of task or action
ACTIVITY LIMITATIONS are difficulties in executing tasks/activities

ex: walking, feeding, dressing, gait, transfers, lifting, driving, sitting, vacuuming, work tasks

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7
Q

ICF Domains:

PARTICIPATION

A

involvement in life situation
PARTICIPATION RESTRICTIONS problems experienced when involved w/ life situations

ex: social relationships, home life/assistance, education, work and employmen, economic life, athlete, volunteer, caregiver, community, social, etc.

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8
Q

Contextual factors of ICF:

A

Environmental factors:

  • all aspects of external/extrinsic world that impact person’s function
  • subdomains: prodcuts/technology, natural environment, support and relationships, attitudes, services, systems, polocies
    ex: going up stairs in class

Personal factors:

  • background of individual’s life
  • features of the individual NOT part of health condition
    ex: sex, race, age, health conditions, fitness, habits, upbringing, social backround, character style
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9
Q

PT role in ICF

A

working knowledge of pathology (health condition)

determine difficulties in task performance/effect on activity and participation
ex: can’t lift shoulder

discover impairments that contribute to task performance and intervene at that level
ex: hypothesize impairment during interview- weakness, strength

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10
Q

Chart Review settings/goals

A

hospitals, acute rehab, nursing home, old charts for outpatient

Goal: patient histpry, understand what’s going on, max info to help examine/eval patient

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11
Q

Things to take from chart review

A
  • current condition
  • general demographics
  • medications
  • other clinical tests/findings
  • social history/health habits
  • sometimes family history/living environ
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12
Q

Sections of Medical Chart

A
  1. History and physical
  2. Progress notes from physicians
  3. Physician orders (LOOK FOR FIRST)
  4. Nursing notes
  5. Consultations
  6. Lab results
  7. Orders
  8. Radiological studies
  9. Admin data
  10. Discharge summary
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13
Q

Things other than chart to review before seeing patient?

A

nursing assessment
referall from physician
medial history forms/health screens
Self-reported outcome measures (DASH, LEFS, PDQ-39, SF-36)

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14
Q

What is a patient-centered interview

A

communicate and understand “person” of the patient
includes patient in interview process- get the whole story

establishes patient rapport, therapeutic relationship, info/data to determine if appropriate

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15
Q

Steps for Patient centered interview

A
  1. set stage
  2. determine agenda and cheif complaint
  3. history of present illness, non-focused inquiry
  4. history of present illness, focused, about symptoms
  5. transition to clinician-centered interview
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16
Q

PCI Step 1: Set stage

A 
welcome patient, with their name
introduce yourself and say role (PT)
ensure patient is ready and privay
remove barriers of communcation (eye level, external noise)
ensure comfort of patient
17
Q

PCI Step 2: Determine Agenda/Cheif Complaint

A

indicate time available, your own needs
obtain list of all issues patient wants to discuss
summarize/finalize agenda: negotiate specifics

18
Q

PCI Step 3: History of Present illness, non-focused

A

open-ended questions and link to CC
nod, eye contact, etc.
get info from nonverbal cues, physical charateristics, environ, etc.

19
Q

PCI Step 4: History of present illness, focused

A

symptom story- narrative of symptoms
personal story- personal/psychological context of symptoms (impact on life)
emotional story
expant the story- identify and deepen as needed

20
Q

PCI Step 5: Transition to Clinician-centered

A

give brief summary
check accuracy
indicate that both content and style of inquiry will change when theyre ready

get mores specifics- details about pain, when where comes out, etc.

21
Q

Differences in interviewing by clinical settings

A

Acute/inpatient: level of cognition, diff goals, diff eye level if sitting
Rehab
Home health: diff environment to work in
Outpatient: higher level of function
School: pediatrics need to tailor to kids
Wellness

22
Q

Types of Questions to ask

A 
ACUTE:
Reason for visit
Prior level of function
discharge situation
precautions if surgery
OUTpatient:
reason for visit/service
location of symptoms
mechanism of injury
24 hour behavior
aggs/eases
23
Q

What is SINS

A

determines how aggresive PT exam may be

SEVERITY
IRRITABILITY
NATURE
STAGE

24
Q

SINS: Severity

A

intensity of symptom
limiation of activites

ex: mild, mod, server; scale of 1-10; face scale

25
Q

SINS: Irritability

A

time to onset of symptoms
time till dissaption
relationship between those times

ex: irratble tissues easily provoked and take time to subside

26
Q

SINS: Nature

A 
Describe symptoms (tingling, radicular, weakness, bowel changes, etc)
Describe pain (sharp, aching, burning, etc.)
PT interpretation of possibly pathology (ex: radiating could be nerve vs. weakness could be muscle)
27
Q

SINS: Stage

A
  1. Progression and stability of simptoms
    ex: improving, stable, or unstable
  2. Time frame for tissue/injury healing
28
Q

SINS-Stage: Examples of time to healing

A

Tissue healing:
inflam- 48-72 hrs up to 10 days
proliferative tissue formation- 10 days-6 weeks
remodeling- 6 weeks-12 months

Injury based healing:
acute 3 months

Patient Management (10 decks)

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