Communication, Documentation, and the ICF Model Flashcards
What are the four types of communication?
1) Verbal
2) Nonverbal
3) Audiovisual AIDS and Assistive Technology
4) Written
Communication in medical encounters comprises of what two aspects?
Verbal and Non-Verbal Aspects
If verbal and non-verbal forms of communication are inconsistent or contradictory, what will override what?
The non-verbal messages tend to override the verbal messages
What four things should you consider with verbal communication?
1) Consider tone and volume
2) Use lay terms that give direct information
3) Be brief and concise for safety and instructions
4) Assess the patients understanding
What kind of tone is ideal to have?
- Calming
- Stimulating
What makes up most human communication?
Non-verbal communication
What is considered to be more effective: verbal or nonverbal communication?
Non-verbal communication
What are examples of non-verbal communication?
- Appearance: dress, grooming, cleanliness
- Body Movements: abrupt, slow, threatening, caring
- Body Positions: sitting, standing, walking, kneeling
- Facial Expressions: smiling, frowning, grimacing
- Gestures: using hands and arms to guide or direct
- Pantomime: demonstrating the activity
- Posture: erect, slouched, rigid
- Spontaneous response to stress: blushing, perspiring, trembling
- Touch: therapeutic, caring, directive, guiding
What is active listening?
Specific way of hearing what a person says and feels and reflecting that information back to the speaker
What is the goal of active listening?
Listen to the whole person and provide them with empathetic understanding
What is the difference between empathy and sympathy?
- Empathy is considered to be compassion and understanding for another person
- Sympathy is considered to be pity for another person
What is better for patient care: empathy or sympathy?
Empathy
According to studies, negative _____ and lack of _____ can worsen outcomes and can even have a small affect on pain.
Expectations; Empathy
What are the four reasons we preform active listening?
1) Shows patients you care
2) Establishes trust and helps build rapport
3) Lessens chances of erroneous treatment/ decision-making, based on your assumptions
4) Increases chances that you’ll get relevant information
There are lots of ways to active listen, what are the 6 main categories?
1) Undivided Attention
2) Body Language
3) Respect
4) Acknowledgement/ Attentiveness
5) Nonjudgemental Attitude
6) Response
What are some barriers to effective communication?
- Physical distance
- Noise and environmental distractions
- Receptive Deficits
- Decreased feedback
- Different interpretations
- Use of complicated vs lay language
- Cultural, gender, or age differences
- Illegible writing
- Inefficient multitasking
What is an example of patient first language?
“My patient has” or “My patient with”
The ICF model is a _____ _____ which can be used to interpret clinical information in a way that focuses on ability.
Conceptual Framework
The ICF model provides what kind of language and framework for the description of health and health-related states?
Standard Language
The ICF model is necessary to aide in what?
The clinical decision making process
What makes up an ICF model?
- Health Condition (ex: total knee)
- Body Functions and Structures (ex: ROM, Strength, Pain)
- Activity (ex: Running, Swimming, Biking)
- Participation (ex: Triathlete)
- Environmental Factors (ex: Car, Bike)
- Personal Factors (ex: Age, Gender)
Body Functions are …
physiological functions of body systems (including psychological functions)
Body Structures are …
anatomical prats of the body such as organs, limbs, and their components
Impairments are …
problems in the body function or structure such as a significant deviation or loss
Activity is …
the execution of a task or action by an individual
Participation is …
involvement in a life situation
Activity Limitations are …
difficulties an individual may have in executing activities
Participation Restrictions are …
problems an individual may experience in involvement in life situations
Environmental Factors make up …
the physical, social and. attitudinal environment in which people live and conduct their lives
Documentation is a written form of _____.
Communication
Any entry into a patients permeant health record is protected by _____.
HIPAA
Clinical documentation of patients is a professional responsibility and a ______ ______.
Legal requirement
Documentation is critical to ensure what?
That individuals receive appropriate, comprehensive, efficient, person centered, and high-quality health care services throughout the episode of care
Most hospitals at this time use what kind of health record?
Electronic medical records (EMR)
What are the 5 reasons we document?
- You legally have to
- Used to reflect best practice in patient care
- Necessary for payment and reimbursement
- Demonstrates compliance to avoid risk
- Serves as a narrative for you and those working with you to follow a plan of care (POC)
What does S.O.A.P. stand for?
- Subjective
- Objective
- Assessment
- Plan
What is your subjective and what is a part of it?
- The history section
- Chart review, patient chief complain (CC)
What is your objective and what is a part of it?
- The physical exam and laboratory data section
- Lab findings, examination, physical exam results
What is your assessment and what is a part of it?
- Your assessment of the patients problems
- Treatment diagnosis based on subjective/ objective findings
What is your plan and what is a part of it?
- Your plan for the patient based on the problems you’ve identified
- Planned interventions, frequency of treatment, goals for patient
The subjective includes anything the patient, family member, or caregiver tells you in addition to what?
What is found in the history and physical (H&P)
The subjective includes but is not limited to:
- History of present illness (HPI)
- Mechanism of injury (MOI)
- Chief complaint (CC)
- Information about lifestyle (living environment or situation)
- Date of injury/ onset date (DOI)
- Past medical history (PMH)
- Prior and current levels of function (PLOF and CLOF)
- Patients goals for PT
Where do you document the results of all your testing/ screenings?
Objective
Where do you document everything you intervened on?
Objective
The clinical impression (general impression of the patient), also considered to be the subjective plus the objective, goes in what part of your note?
Assessment
What part of the note would you link the impairment found in the initial examination to the patients activity limitations and participation restrictions?
Assessment
The assessment provides proof that skilled physical therapy is what?
Medically necessary
Your plan should include what 5 things?
- Plan of interventions to address impairments, activity limitations and participation restrictions
- Frequency of visits
- Expected number of visits
- Goals
- Discharge recommendations
What are the two types of goals?
- Long term goals (LTG)
- Short term goals (STG)
How should goals be written?
S.M.A.R.T.
- Specific/ Significant
- Measurable/ Meaningful
- Achievable/ Action-Oriented
- Relevant/ Realistic
- Time-based/ Trackable
When someone says a goal needs to be measurable, what does that mean?
It is: quantifiable, assessable, clear, calculable, determinate, finite, verifiable
