Exam 1 (Lecture 8) Flashcards
medical history to keep in mind with PTs
setting: where is PT being seen?
are they healthy or undergoing systemic/local disease treatments
can PT effectively communicate (do they understand what you are asking them)
do they need help communicating
what are barriers PT experiences to communicating effectively with us
HL, decreased vision, speech production problems (use WIPI (>5 yrs) - strokes, laryngectomy, etc.), cognitive/memory issues, & language/cultural diversity
what help can PTs have to communicate
HAs
assistive listening devices
interpreters
family members/caregivers
when taking a hx with an adult include
History of ear surgeries and trauma/concussion - attention so they cannot attend as well as they should
History of recent hospitalizations - might not share things because they dont see the relevance (like cancer etc.)
Drug history including all OTC medications
History of specific diseases - diabetes (type 1 or 2 - directly affects hearing), blood pressure (low & high - affects heart, vasculature and kidneys), bleeding disorders (practical implications like in earmolds),
when taking a hx with an children include
pregnancy, birth & delivery hx
meds used & meds mom took during and right after pregnancy
NBHS results
Academic and developmental history including language
Otitis media and upper respiratory tract infections
Infectious diseases such as CMV, Zika, measles, and meningitis
History of ear surgeries, hospitalizations, trauma, & concussion
History of tumors requiring chemotherapy and/or radiation
Academic history
Family history of genetic and hearing/vestibular disorders
Social history
primary concerns
reason for the visit, what does the PT want addressed
PTs perceived reason for the visit can differ from what the professional referred for
what happens if a clinician doesn’t address the primary concern
if this is not addressed, PT fels ignored, put off etc.
affects rapport & relationship with provider
affects PT compliance with treatment recommendations
most PTs want help returning to
their baseline of health, improve functioning abilities and their quality of life
what do you want to ask during med history
hx list of adult vs kids
primary concerns
what is HIPAA
Health Insurance Portability and Accessibility Act of 1996 (HIPAA) Privacy, Security and Breach Notification Rules
what does HIPAA do
federally protects individuals identifiable health information held by covered entities and their business associates
gives PT rights to that information
PHI
protected health information
privacy rule of HIPAA
balanced to permit disclosure of health information needed for patient care and other important purposes - who can you share that information with
security rule of HIPAA
specifies a series of administrative, physical, and technical safeguards for covered entities and their business associates to assure the confidentiality, integrity, and availability of electronic protected health information
what is important to remember for confidentiality
medical history reveals personal information
be aware of surroundings and how the information is handled
where are you taking the case history, who can hear you, who is around you?
