Documentation and Hand Hygiene Flashcards
ICF, Assessment, Prognosis, POC, and SBAR
List possible reasons for denial from insurance companies
- no documentation for date of service
- incomplete documentation
- misunderstood abbreviations
- goals not written as functional outcomes
- medical necessity not ID
- does not support the billing (code)
- does not demonstrate progress
- does not demonstrate skilled care
define differential diagnosis
a list of possible conditions or diseases that could be causing your symptoms
T/F: the differential diagnosis list developed by the PT can only have one diagnosis
FALSE
may include several conditions
define medical diagnosis
the anatomic, biochemical, physiologic, or psychologic derangement
a labeling pathology
PT’s do not make these!
define physical therapy diagnosis
the primary dysfunction toward which the PT directs treatment
includes an element of function
PTs make these!
define primary diagnosis
condition established to be chiefly responsible for patient to seek medical care
*the reason they are coming to PT
ex: total knee replacement, CVA, patellofemoral pain syndrome
define secondary diagnosis
any additional conditions that affect patient care
other conditions/co-morbities
what portion of the PT documentation should be the best and stand out?
Assessment
after gathering the patient history and performing tests and measures the PT must first determine what?
- if PT/intervention is appropriate for the patient
- if consultation with another healthcare provider is necessary
- if PT/intervention is not appropriate and the patient must be referred elsewhere
T/F: the assessment introduces new subjective and objective data?
FALSE
how does the ICF model relate to writing an assessment?
it serves as a model that helps us to tie all the pieces together
link medical and PT dx w/impairments, activity limitations, and participation restrictions
define impairment pertaining to the ICF model
any problem an individual may have in body function or structure
define activity limitation pertaining to the ICF model
difficulty in executing tasks:
- ADLs (basic)
- functional mobility
- learning
define participation restrictions (pertaining to the ICF model)
problems in life roles
- work activities
- community activities
- leisure activities
- relational activities
when you write an assessment, think Bob Ross. Why?
your assessment should paint a picture to anyone who reads it and make it clear what is going on with the patient and how you are going to help
what conditions must be met in order for PT services to be deemed reasonable and necessary?
- services provided are consistent with nature and severity of the illness, injury, and medical needs
- the services provided are specific, safe, and effective TX for the condition according to accepted medical practices
- observable improvement in functional ability is expected to occur
- services provided don’t just promote general welfare of patient
T/F: the assessment can never change once it has been written?
FALSE
it can change based on new or changing info
list some tips to remember when attempting to demonstrate progression and justify PT services
- document previous as compared to current function
- use percentages, levels of assistance or function but make sure they can be easily understood
- use standard outcome measures
what are the 5 moments of hand hygiene?
- BEFORE touching a patient
- BEFORE clean/aseptic procedures
- AFTER a body fluid exposure risk
- AFTER touching a patient
- AFTER touching a patient’s surroundings
T/F: gloves take the place of proper hand hygiene?
FALSE
what are HAIs?
Health-care related infections
infections that people get while recieving health care for another condition
T/F: hand hygiene is the undisputed single most effective infection control measure in prevention of HAIs?
TRUE
what is including in the “patient zone”?
the patient, surface and items that are temporarily and exclusively dedicated to him/her
(everything the patient has been exposed to)
what is included in the health care area?
all surfaces in the health care setting outside of the patient zone
how long should the entire procedure of washing hands take? what about when using hand sanitizer?
40-60 seconds (including set up and drying hands)
20-30 seconds (with hand sanitizer)
What are standard precautions?
a group of infection prevention practices applied during care of all individuals, regardless of suspected or confirmed infection status, in any health care setting
List the elements included in standard precautions
- hand hygiene
- PPE
- resident placement - single resident rooms or cohorting
- respiratory hygiene/cough etiquette
- safe injection practices
- textiles and laundry handling
List times when you should wear gloves
when there is any anticipated contact with:
- blood or body substances
- mucous membranes
- non-intact skin
- indwelling device insertion site
- handling potentially contaminated items in the resident’s environment
List times when you should wear gowns
- during procedures likely to generate splashes, sprays or droplets of blood and body fluids
- when in contact with non-intact skin
- handling fluid containers likely to leak, splash or spill when moved
what are transmission-based precautions?
specific practices added to standard precautions when the spread of infection or organisms is not completly stopped using standard precautions alone
what are the different types/subtypes of transmission-based precautions?
- contact precautions
- droplet precautions
- airborne precautions
What are contact precautions?
prevention of transmission of infectious pathogens that are spread by direct or indirect contact with a resident or their environment
List some illness that require contact precautions
- uncontained excessive wound drainage
- uncontained fecal or urine incontinence or other body fluids
- infections or colonization with MDROs or other epidemiologically significant organisms
Contact precautions include what additions to standard precautions?
- wearing gloves and gowns
- use of disposable equipment per patient
- cleaning and disinfecting resident room at least daily, w/focus on high touch surfaces
what are droplet precautions?
prevention of transmission of infectious pathogens that are spread to others by speaking, sneezing, or coughing
droplet precautions include what additions to standard precautions?
wearing gloves and masks
what are airborne precautions?
prevention against transmission of airborne pathogens
(occurs through dissemination of either airborne droplet nuclei or dust particles containing infectious agent)
List some common diseases that require airborne precautions
- Measles
- Severe Acute Respiratory Syndrome (SARS)
- Varicella (chickenpox)
- TB
airborne precautions include the addition of what to standard precautions?
masks and respirators
place patient in airborne infection isolation room (AIIR)
What are AIIR?
Airborne infection isolation room
provide negative pressure to keep airbone droplets/dust from escaping the room
or has an exhuast to the outside or through HEPA filtration
define prognosis
the predicted level of improvement in function and amount of time needed to reach that level
when is the prognosis determined?
after the establishment of the diagnosis
what information must be included in the prognosis?
- predicted optimal level of improvement in function
- amount of time needed to reach that level
- must also influce a discussion of factors likely to influence prognosis to justify your reasoning for determining the prognosis
List some factors that can influence the prognosis
- age
- prior health status
- motivation/patient compliance
- psychosocial and SES factors
- availability of resources
- concomitant conditions
where is the prognosis documented in the intial eval?
in either the POC or Assessment
how should the prognosis be stated in documentation?
graded as either excellent, good, fair or poor
along with details that influenced your judgement/grade and a discussion of those factors
T/F: a one word statement is good enough for a prognosis?
FALSE
the statement needs to be substantiated by your clinical reasoning for coming to this conclusions
what is the purpose of the Plan of Care (POC)?
it specifies the general interventions to be used and anticipated frequency and duration of PT visits
List the components of the POC
- specific goals
- predicated level of optimal improvement/anticipated DC plans
- general interventions to be used
- proposed duration and frequency
What criteria should be included in a goal?
- patient centered
- objective
- measurable
- functional
- time-dependent
It is important to relate goals back to ______
function
impairments, activity limitation and participation restrictions
T/F: the predicted level of optimal improvement needs to be included in both the POC and assessment?
FALSE
it can be in either of these sections but only needs to be in one
when listing specific interventions to be used, what things should you keep in mind?
- indicate broad areas of intervention necessary to achieve goals
- interventions implemented need to be consistent with diagnosis and prognosis of patient
- indicate how the intervention will be delivered (by the PT/PTA/other healthcare memeber)
Modification of a POC requires ___________
a reevaluation
Alterations to a POC need to occur with a patient change of status. What constitutes a change in status?
patient’s function has: diminished, not changed, or improved
List the components of a reexamination
- clinical impression or diagnosis
- objective reassessment of tests and measures and outcome tools
- goal status
- evaluation
T/F: Hospital medical errors are the 3rd leading cause of death in the USA
TRUE
communication failure is the root of this 70% of the time
What model is used within Healthcare to effectively communicate between healthcare workers?
SBAR
what does SBAR stand for?
- Situation
- Background
- Assessment
- Recommendation
who created SBAR?
the navy submarine division
