Documenting Activities Flashcards

1
Q

Patient-Specific Orders

A
  • Restrictions/Precautions
  • Weight bearing status
  • Activity Orders

Gather these in the medical chart review; If you don’t know and don’t have access ask the patient for information then ask their physician.

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2
Q

Restrictions

A
  • Setting dependent restrictions
    – Visitors (Number limit or covid)
    – Monitoring devices (Don’t detach unless allowed)
  • Post-surgical restrictions
    – Related to drains/tubes
    – Positioning (THA)
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3
Q

Infectious Disease Precautions

A

Require additional PPE and treatment setting considerations:
– Contact
– Droplet
– Airborne

With precaution may not be able to go to specific places in a hospital.

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4
Q

Contact precaution

A

patient has a condition that is transmitted by direct contact with a person or items in their environment (C-Diff, draining wounds)

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5
Q

Droplet precautions

A

patient has a condition transmitted by large particle droplets of sputum or mucus (strep throat, whooping cough, flu)

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6
Q

Aireborne precautions

A

patient has a conditiontransmttedthrough the air (TB, COVID, SARS)

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7
Q

Weight Bearing Restrictions

A
  • variation in interpretation of Lower Extremity and sometimes upper extremity
  • based on patients BW that should be transmitted through limb
  • Cannot use documentation to describe gait
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8
Q

Non-weight Bearing (NWBing)

A
  • Foot does not touch the ground
  • Upper extremity cannot be used for support
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9
Q

Toe-touch Weight Bearing (TTWBing)

A

Foot contacts ground for balance only
Only up to 20% of body weight

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10
Q

Partial Weight Bearing (PWBing)

A

Designated as 20-50% of body weight

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11
Q

Weight Bearing As Tolerated (WBAT)

A

Limited ONLY by patient tolerance (usually 50-100%)

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12
Q

Full Weight Bearing (FWBing)

A

No restriction / 100% WBing

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13
Q

Give an example of Weight Bearing

A

NO “patient is WBAT, when walking, demonstratesTTWBing”

YES “orders for WBAT on B LEs; noted when patient was participating in transfers / ambulating, put decreased weight through R LE during stance; patient indicates this is due to increased R knee pain to 7/10 in stance”

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14
Q

Activity Orders and Progressions

A
  • Bedrest (strict – not out of bed for any reason)
  • Bedrest with Bathroom Privileges / Commode Privileges
  • Dangle at Edge of Bed (may be specific with durations)
  • Up to Chair (may be specific with durations)
  • Activity as Tolerated (no restrictions, but must be supervised / may require assistance for mobility)
  • Up Ad Lib (no restrictions, can walk freely about the room and unit)
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15
Q

Elements of Documentation

A
  • Clear and defensible
  • Needs to reflect all relevant aspects of the patient encounter in a way that can be understood by all members involved in the patient’s care and can be reproduced by other professionals
  • Needs to be timely (Same day)
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16
Q

Functional Mobility Tasks

A
  • Bed mobility
    – Rolling
    – Shifting
    – Re-positioning
    – Supine to/from sitting
  • Transfers
    – Sit to/from stand
    – Lateral transfers (pivot, slide board, lift)
  • Ambulation
  • Stair navigation
  • Wheelchair mobility

Assistance, guidance, help are reasons for skilled PT. All examples above.

17
Q

Ambulation and Distance

A
  • Ambulation <50 feet (between a few rooms in a home with rest between trips)
  • Ambulation 50-150 feet (full household ambulator)
  • Ambulation > 150 feet (community ambulator)

Always document how far they went.

18
Q

Assistive Devices Utilized

A
  • Bed Mobility
    – Rails, Trapeze
  • Transfers
    – Lift, gait device, rails, slideboard
  • Ambulation
    – BW Support, Gait device
  • Stairs
    – Railings, side of rail
  • Slings/Orthoses
19
Q

Levels of Physical Assistance

A
  • Independent
  • Supervision
  • Standby Assist/ SBA
  • Contact Guard Assist/ CGA
  • Minimal Assist/minA
  • Moderate Assist/ModA
  • Maximum Assist/maxA
  • Dependent

How much assistance the patient requires to successfully and safely complete the task
Specific cues (manual or verbal)
May require more than 1 person

20
Q

Independent

A

No manual assist, supervision, or cues (can use device)

21
Q

Supervision

A

Not directly next to patient, observes task, ready to provide cues

22
Q

Standby Assist/ SBA

A
  • Ready to provide manual assist, but close
  • No hands on
23
Q

Contact Guard Assist/CGA

A

1 or 2 hands in contact, with or without cues, balance support

24
Q

Minimal Assist/minA

A

Provider does 25% of work / patient does 75% of work

25
Q

Moderate Assist/modA

A

Provider does 50% of work / patient does 50% of work

26
Q

Maximum Assist/maxA

A

Provider does 75% of work / patient does 25% of work

27
Q

Dependent

A

Provider does 100% of work / lift dependent

28
Q

Other Considerations for Documentation

A
  • What are the limiting factors in participation?
    – Pain?
    — Ratings
    — Location
    – Fatigue?
  • Did they need extra time?
    – Why?
  • How many repetitions were they able to complete?
  • Do they perform consistently?
  • How far were they able to ambulate or propel the wheelchair?
  • Can they perform in a variety of environmental conditions?

Make sure it is measureable, give values

29
Q

Plan of Care - Goals

A
  • A (actor) – who will accomplish goal?
  • B (behavior) – what is expected task / activity?
  • C (conditions) – with what devices? With what level of assist?
  • D (degree) – consistency? Frequency? What environment / context? Efficiency?
  • E (expected time) – setting specific
30
Q

Identify the missing components of the goals below:
1. Patient will complete transfers independently.
2. Bed mobility with railings in 2 weeks.
3. Patient will demonstrate improved right knee flexion to 80 degrees in 2 days.
4. Patient will complete sit to/from stand and pivot transfers using 2ww andminAx 1 for guidance of R LE by 3/2/21.

A
  1. Patient will complete transfers independently.(Time, Type of transfer, environment/context)
  2. Bed mobility with railings in 2 weeks. (Type of mobility, patient, any assistance?)
  3. Patient will demonstrate improved right knee flexion to 80 degrees in 2 days.(assistance?, need to tie a function to their condition/context)
  4. Patient will complete sit to/from stand and pivot transfers using 2ww andminAx 1 for guidance of R LE by 3/2/21.(too many tasks)
31
Q

Examples of Well Written Mobility/Activity Goals:
Pt. will complete bed mobility & transitions withminAx 1to manage R LE prior to discharge to home setting.
Pt. will complete sit to/from stand and pivot transferswith 2ww &modAx 1 for boost / lower prior to dischargeto SNF.
Pt. will ambulate up/down 4 steps using single railing andCGA x 1 for safety prior to discharge to home setting.

A

Cannot discharge a patient ONLY physicians