Chart Review, ICF, Patient Centered Interview Flashcards
What does the ICF model do?
framework for communicating and studying impact of disease on ability to interact w/ environment
common language to delineate consequences of disease and injury
WHO on ICF
- 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
What does ICF emphasize
components of health over consequences of disease
Participation over disability
Role in society
Environ and personal factors contributing to overal “health”
Considers WHOLE person
3 levels of human function in ICF
Function at level of BODY PARTS (physio)
Function at level of WHOLE PERSON
Function of whole person in their COMPLETE ENVIRON
ICF Domains:
BODY STRUC and FUNCTION
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.
ICF Domains:
ACTIVITY
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
ICF Domains:
PARTICIPATION
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.
Contextual factors of ICF:
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
PT role in ICF
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
Chart Review settings/goals
hospitals, acute rehab, nursing home, old charts for outpatient
Goal: patient histpry, understand what’s going on, max info to help examine/eval patient
Things to take from chart review
- current condition
- general demographics
- medications
- other clinical tests/findings
- social history/health habits
- sometimes family history/living environ
Sections of Medical Chart
- History and physical
- Progress notes from physicians
- Physician orders (LOOK FOR FIRST)
- Nursing notes
- Consultations
- Lab results
- Orders
- Radiological studies
- Admin data
- Discharge summary
Things other than chart to review before seeing patient?
nursing assessment
referall from physician
medial history forms/health screens
Self-reported outcome measures (DASH, LEFS, PDQ-39, SF-36)
What is a patient-centered interview
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
Steps for Patient centered interview
- set stage
- determine agenda and cheif complaint
- history of present illness, non-focused inquiry
- history of present illness, focused, about symptoms
- transition to clinician-centered interview
PCI Step 1: Set stage
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
PCI Step 2: Determine Agenda/Cheif Complaint
indicate time available, your own needs
obtain list of all issues patient wants to discuss
summarize/finalize agenda: negotiate specifics
PCI Step 3: History of Present illness, non-focused
open-ended questions and link to CC
nod, eye contact, etc.
get info from nonverbal cues, physical charateristics, environ, etc.
PCI Step 4: History of present illness, focused
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
PCI Step 5: Transition to Clinician-centered
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.
Differences in interviewing by clinical settings
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
Types of Questions to ask
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
What is SINS
determines how aggresive PT exam may be
SEVERITY
IRRITABILITY
NATURE
STAGE
SINS: Severity
intensity of symptom
limiation of activites
ex: mild, mod, server; scale of 1-10; face scale
SINS: Irritability
time to onset of symptoms
time till dissaption
relationship between those times
ex: irratble tissues easily provoked and take time to subside
SINS: Nature
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)
SINS: Stage
- Progression and stability of simptoms
ex: improving, stable, or unstable - Time frame for tissue/injury healing
SINS-Stage: Examples of time to healing
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
