Exam 2: Guide Note for Documentation

Question 1

What are four aspects that go into a physical therapist decision making?

Answer 1

refer, retain, co-manage, consult

Question 2

Which one of these 4 are the most important?

Answer 2

retaining

Question 3

What are the aspects of retaining a patient?

Answer 3

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

Question 4

What is the biopsychosocial model?

Answer 4

the person is in the middle of a even diagram with psychology, social environment and biology

Question 5

What are the three aspects of evidence based practice?

Answer 5

best available evidence, clinical expertise, patient/client values and circumstances

all equally important

Question 6

What are the four goals of the ICF?

Answer 6

1. provide scientific basis for consequences of health conditions
2. establish a common language to improve communication
3. permit comparison of data across: countries, health care disciplines, services and times
4. provide a systematic coding scheme for health information systems

Question 7

What are the 6 components of patient management model?

Answer 7

1. examination
2. evaluation
3. diagnosis
4. prognosis
5. intervention
6. outcomes

Question 8

How is the history of a patient conducted?

Answer 8

chart review, speaking with other members of health team, patient interview

Question 9

What does the history consist of ?

Answer 9

1. review of systems and Systems screen

Question 10

What is the ROS?

Answer 10

anything medically related (green, yellow or red flags)

Question 11

What is systems screen?

Answer 11

PT specific finds that are not for your reason for treatment

EX: cp, ms, integ, musculoskel

Question 12

What can you get from a systems screen?

Answer 12

information from this can lead to what tests and measures you get

however these are not measurements but observations

is it safe to treat?

Question 13

Can an objective test be subjective?

Answer 13

yes, b/c you’re looking at something

Question 14

What are some examples of objective tests and measures?

Answer 14

strength, ROM, inspection, balance, vitals, functional mobility

Question 15

What can standardized tests measure?

Answer 15

aerobic capacity, balance, function, special diagnostic tests

Question 16

What is the definition of a PT evaluation?

Answer 16

is the PT’s constant clinical decision making and judgements about the examination data

Question 17

What does the evaluation lead to?

Answer 17

further examination, PT diagnosis, termination of exam, referral to other providers

Question 18

What does PT diagnosis revolve around?

Answer 18

function, not a medical diagnosis, not an impairment

Question 19

What is a prognosis?

Answer 19

the optimal level of improvement that will be attainable with PT intervention in that setting

Question 20

What is rehab potential ?

Answer 20

patients ability to meet their goals

Question 21

What are the four types of rehab potential?

Answer 21

1. poor- 50% chance or less of meeting goals
2. fair- 75%
3. good- 76+
4. excellent 90+

must be clarifying comments to support your choice

Question 22

What are components of a good goal?

Answer 22

1. functional
2. measurable
3. accurate
4. have a time frame

Question 23

In regards to patient interventions what is patient related instructions?

Answer 23

education- very important

home exercise program

Question 24

What are direct interventions?

Answer 24

therex, aerobic capacity training, airway clearance technique