Exam 2: Guide Note for Documentation Flashcards
What are four aspects that go into a physical therapist decision making?
refer, retain, co-manage, consult
Which one of these 4 are the most important?
retaining
What are the aspects of retaining a patient?
developing plan of care, attaining accountability for that plan of care, defines boundaries for others assisting in the service, always has the option of handling all aspects of service alone
What is the biopsychosocial model?
the person is in the middle of a even diagram with psychology, social environment and biology
What are the three aspects of evidence based practice?
best available evidence, clinical expertise, patient/client values and circumstances
all equally important
What are the four goals of the ICF?
- provide scientific basis for consequences of health conditions
- establish a common language to improve communication
- permit comparison of data across: countries, health care disciplines, services and times
- provide a systematic coding scheme for health information systems
What are the 6 components of patient management model?
- examination
- evaluation
- diagnosis
- prognosis
- intervention
- outcomes
How is the history of a patient conducted?
chart review, speaking with other members of health team, patient interview
What does the history consist of ?
- review of systems and Systems screen
What is the ROS?
anything medically related (green, yellow or red flags)
What is systems screen?
PT specific finds that are not for your reason for treatment
EX: cp, ms, integ, musculoskel
What can you get from a systems screen?
information from this can lead to what tests and measures you get
however these are not measurements but observations
is it safe to treat?
Can an objective test be subjective?
yes, b/c you’re looking at something
What are some examples of objective tests and measures?
strength, ROM, inspection, balance, vitals, functional mobility
What can standardized tests measure?
aerobic capacity, balance, function, special diagnostic tests
What is the definition of a PT evaluation?
is the PT’s constant clinical decision making and judgements about the examination data
What does the evaluation lead to?
further examination, PT diagnosis, termination of exam, referral to other providers
What does PT diagnosis revolve around?
function, not a medical diagnosis, not an impairment
What is a prognosis?
the optimal level of improvement that will be attainable with PT intervention in that setting
What is rehab potential ?
patients ability to meet their goals
What are the four types of rehab potential?
- poor- 50% chance or less of meeting goals
- fair- 75%
- good- 76+
- excellent 90+
must be clarifying comments to support your choice
What are components of a good goal?
- functional
- measurable
- accurate
- have a time frame
In regards to patient interventions what is patient related instructions?
education- very important
home exercise program
What are direct interventions?
therex, aerobic capacity training, airway clearance technique
