Exam 1 Flashcards by Gabrielle Otremba

what are the four types of patient/client notes?

initial evaluation - first patient encounter
daily note - after every session
progress (1x/week) or reeval (1x/month)
discharge - when therapy is completed

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what part of the patient encounter is collecting subjective information?

discussion with patient
patient’s verbal communication concerning the chief complaint
not always accurate
be specific

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are you only collecting subjective information from the patient?

no - physician, family, caretaker, etc

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where do you start when collecting subjective information

who
what happened
when did it happen
where did it happen
who did it happen

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what could you do while actively listening when collecting subjective information?

process the information
observing non-verbal cues
direct objective choices

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what does the mneumoic “old charts” stand for?

O: onset - when
L: location - where
D: duration - how long

CH: character - description
A: alleviating/aggravating factors: better or worse
R: radiation - does it stay in one area or move
T: time - time of day better or worse
S: severity - sharp, dull, aching, pain scale

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why is it important to NOT miss the past medical history portion of the subjective?

red flags

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what are you collecting in the past medical history part?

previous injuries, surgeries or incidents
allergies
alcohol
family history
social history
work
school

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dont chase _________

pain or symptoms

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what type of information is the objective collecting?

helps formulate assessment and plan
measurable
reliable
repeatable

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what are the two sub sections of the objective?

systems review
tests and measures

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what is the purpose of the systems review in the objective?

briefly reviews key fields of the patient in a global context
can also serve as a guide to refer patient out
used to help guide more specific tests and measures

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can the systems review also be included in questionnaire that patient fills out?

yes

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what are the 3 key elements featured in the tests and measures?

repeatable
valid
reliable

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what would the categories look like in tests and measures?

organized
easy to read
easy to find
* may not use every category for every patient

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what are the categories under tests and measures?

observation
palpation
ROM
MMT
sensation
special tests
gait
transfers
balance

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increase _______ of each category based on patient

specificity

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how do you know you’re complete with subjective and objective parts?
make sure your information is ______

if you have enough information to proceed to the evaluation (assessment and plan)
focus on what information is relevant

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the ICF model is designed to ?
it acknowledges the interaction of ?

designed to establish a framework for a comprehensive health measurement - focuses on ability

acknowledges the interaction of contextual factors

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what are the factors that affect activity?

health condition - represents medical disorder or disease
participation - starting to be combined with activity
body functions and structures - impairments. ROM, strength, mobility, joint functions
contextual factors - environmental and personal

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what are environmental factors?

physical environment

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what are personal factors?

factors specific to that patient
age, gender, experiences, education, social, support system

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what is disability?

impairments in body structure and function
activity limitations and participation restrictions

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what are factors that promote positive health?

facilitators

what are factors that impede health?

barriers

assessment includes linking:

impairments activity limitations participation restrictions

what is critical thinking?

analyzing knowledge based on evidence and science - knowledge of the subject

what is clinical reasoning?

application of critical thinking within the clinical setting - relevance of knowledge and evidence

what is clinical judgement?

reflecting on clinical thinking and clinical reasoning in determining assessment of patient's problem - conclusion about patient's health problems and what action is or is not needed

an assessment includes what three things?

evaluation diagnosis prognosis

what is the key purpose of the evaluation?

summarize the PTs clinical judgment

what things are mandatory in a SOAP note?

provides accurate and brief summary justify continued PT intervention assists in location of impairments and restrictions

what is the purpose of the diagnostic statement?

- describe relationship between examination findings - connecting patient's limitations and restrictions to impairment and medical diagnosis - key to reflect the therapist's thinking and justification of needed treatment

true or false. diagnosis will include functional deficits

true

diagnosis and statement needs to be stated so it is easily understood by who?

other professionals those making reimbursement decisions who may not have extensive medical knowledge

medical diagnosis uses categories based on what?

categories baed on signs and symptoms

physical therapy diagnosis includes what?

diagnostic statement describing relationship between medical diagnosis and affect on patient's function

when is the prognosis completed?

after examination, evaluation and diagnosis

what does the prognosis predict?

level of improvement in activities participation amount of time needed

what also needs to be considered in a prognosis?

complexity level of evaluation - low, medium or high

before proceeding to your plan of care, what must you make sure of?

that you have enough information for your assessment

what are the two parts of the plan?

document planned interventions document expected outcomes and anticipated goals

what are anticipated goals?

short term goals stepping stones to achieve expected outcomes

what are expected outcomes?

long term goals final functional status at end of skilled therapy intervention

what are interventions? includes what?

forms of treatment patient will receive during entirety of skilled therapy - includes frequency and duration of skilled therapy

what factors need to be considered for interventions?

alloted time for therapy patient's current physical/mental state patient's support system

what are some examples of interventions?

therex MT patient education modalities balance, gait training functional activities

the number and type of goals depend on the ____ and ______

setting and patient

what are some factors that determine a patient's goals?

diagnosis medical history results of examination clinical judgement

what criteria should goals meet?

SMART goals - with addition of function ABCD structure

goals should be ____ and listed in _____ include ________

clear listed in order of priority include patient's goals/function

goals need to be _______ which means?

measurable it should be quantifiable, assessable, clear, calculable, determinate, finite, verifiable

ABCDE structure:

A - actor: identification of person (patient) B - behavior: description of movement or activity, connection of movement to specific function or participation (task) C - condition: specific conditions in which activity will be performed (environment) D - degree: factors for measuring the outcome quantitatively (objective) E - expected time - time frame for achieving the goal (short term vs long term)

what is an example of a goal written in ABCDE structure?

patient will perform sit to stand in order to transfer out of bed on level surface similar to home independently in 2 weeks

with short-term goals, dependence upon the length of stay should be correlated with ____

the similar long-term goal

in a short term goal, what does the ICF model relate to?

relates to a patient's body function and activity limitations

what should you relate a long term goal to?

discharge goals

in a long term goal, what does the ICF model relate to?

relates to a patient's participation limitations