Documentation Flashcards
Identify whether the info provided is Subjective, Objective or Assessment part:
consent to tx
subjective
Identify whether the info provided is Subjective, Objective or Assessment part:
ROM
objective
Identify whether the info provided is Subjective, Objective or Assessment part:
immediate event prior to illness
subjective
Identify whether the info provided is Subjective, Objective or Assessment part:
poor balance d/t illness
assessment
Identify whether the info provided is Subjective, Objective or Assessment part:
restriction to mvmt because of wheelchair use
assessment
Identify whether the info provided is Subjective, Objective or Assessment part:
medication routine
subjective
Identify whether the info provided is Subjective, Objective or Assessment part:
level of assistance to task
objective
Identify whether the info provided is Subjective, Objective or Assessment part:
uses crutches
subjective
Identify whether the info provided is Subjective, Objective or Assessment part:
pt’s response to illness
subjective
Identify whether the info provided is Subjective, Objective or Assessment part:
favorite food
subjective
Identify whether the info provided is Subjective, Objective or Assessment part:
ano itsura ng bahay niyo
subjective
Identify whether the info provided is Subjective, Objective or Assessment part:
nagsisimba ka ba
subjective
Identify whether the info provided is Subjective, Objective or Assessment part:
Mukhang kailangan pa po natin magtherapy ng mga ilan buwan pa.
assessment
Identify whether the info provided is Subjective, Objective or Assessment part:
alam niyo ba kung anong araw ngayon at kung asan ka?
objective
Identify whether the info provided is Subjective, Objective or Assessment part:
namamaga ang kanan paa at kamay
objective
Identify whether the info provided is Subjective, Objective or Assessment part:
mahina pa ang balanse at koordinasyon ng katawan sa paglalakad
assessment
Identify whether the info provided is Subjective, Objective or Assessment part:
hindi kaya itaas ang binti para makatapak sa hagdan
objective
Identify whether the info provided is Subjective, Objective or Assessment part:
pakitaas ang kamay at idikit sa may tenga
objective
Identify whether the info provided is Subjective, Objective or Assessment part:
mababa tiyansa ng partisipasyon sa paglalakad
assessment
Identify whether the info provided is Subjective, Objective or Assessment part:
anong nangyari bakit ka dinala sa OT
subjective
enumerate what you can find in the subjective findings
- demogs info
- chief complaint
- ot goal
- history of present illness
- context and environment
- performance patterns
- client factors
what should be found in the HPI
- location
- immediate event
- situation
- intervention
- reaction
t/f
a non licensed OT cannot do evaluation and treatment to cx
false
OTA cannot evaluate but can treat but with supervision
habits that interfere with every day activities of cx
dominating habits
what should be seen in the routine part of the cx
premorbid and postmorbid routine
enumerate what are the cx factors
- values
- beliefs
- spirituality
- body fxn
- body structure
what can be found in the objective findings
non/standardized assessment tools
tool used to observe the client in actual performance of the occupation
Dynamic performance analysis
t/f
it is possible to evaluate only one side
false
should be both
part of documentation where you summarize clinical reasoning and write conclusion from acquired subjective and objective findings
assessment
what are included in the assessment part
- strength and weakness
- OT diagnosis
- prioritized problem list
- potential for occupational performance
- table analysis of occupational performance
