ICF/Chart Review/PT Interview

Question 1

What is the ICF model?

Answer 1

emphasizes components of health rather than consequences of diseases

participation rather than disability

role in society

environmental/personal factors

“whole person”

Question 2

3 levels of human function:

Answer 2

body parts
whole person
whole person in their complete environment

Question 3

ICF chart

Answer 3

Health Condition (disease/disorder)

• Body function/structure
• Activities
• Participation
• Environmental/Personal Factors

Question 4

Body function/structure

Answer 4

anatomical parts of the body
physiological functions of the body systems
impairments are problems in structure or function

ex: balance, pain, weakness, muscle tone, contractures, HR, BP, ROM, MMT, Endurance, Pain, sensation

Question 5

Activity

Answer 5

execution of task/action
limitations are difficulties in executing tasks/activities

ex: walking, feeding, dressing, lifting ability, driving, sitting

Question 6

Participation

Answer 6

involvement in a life situation
restrictions are problems experienced when involved in life situations

ex: relationships, home life, assistance to others, education, work, employment, economic life, community, social, parent, caregiver, athlete, volunteer, career

Question 7

Contextual factors

Answer 7

Environmental

Personal

Question 8

Environmental

Answer 8

all aspects of external/extrinsic would that impact’s the person

ex: products/technology
natural environment
human made changes
support/relationships
services, systems, policies

Question 9

Personal

Answer 9

background of individual’s life
features that are not a part of health condition

ex: sex, race, age, health conditions, fitness, lifestyle, habits, upbringing, coping styles, social background, experiences, character, attitudes

Question 10

Steps for patient-centered interview

Answer 10

1) setting the stage
2) determining the agenda and CC
3) history of present illness, non-focused inquiry
4) history of present illness, focused, inquiring about the symptom story, personal story, and emotional story
5) transition to clinical-centered interviewing

Question 11

Step 1) Setting the Stage

Answer 11

welcome the patient
use patient's name
introduction and role
ensure patient's readiness and privacy
remove barriers to communication
ensure comfort and put patient at ease

Question 12

Step 2) Determine Agenda & CC

Answer 12

indicate time available
indicate our needs
obtain list of issues patient wants to discuss
summarize and finalize the agenda

Question 13

Step 3) History of Present Illness, non-focused inquiry

Answer 13

Open ended beginning question, link to CC
Nonverbal cues
Physical characteristics
Autonomic changes
Environment
Interviewer's own feelings

Question 14

Step 4) History of Present Illness, focused inquiry

Answer 14

Symptom story
Personal story
Emotional story
Expand the story

Question 15

Step 5) Transition to Clinician-Centered Interview

Answer 15

Give brief summary
Check accuracy
Indicate that both the content and style or inquiry will change if the patient is ready

Question 16

Question sequencing

Answer 16

Choose questions based on info that is already gathered

Question 17

Goals of patient interviewing

Answer 17

Rapport development
Determine of PT is appropriate
Establish therapeutic relationship

Question 18

SINS

Answer 18

Severity
Irritability
Nature
Stage

Question 19

Severity

Answer 19

Intensity of symptoms (How severe/intense?)
Limitation of patient’s activities (How much is this affecting?)

ex: mild, mod/severe

Question 20

Irritability

Answer 20

Time of onset of symptoms
Time required for symptoms to dissipate
Relationship between these two times and magnitude of symptoms

ex. walking for 10 minutes pain starts, but dissipates right after rest (Irritability is low)

Question 21

Nature

Answer 21

Description of symptoms
ex. tingling, radicular pain/numbness, weakness, sweating, bowel and bladder changes

Can you describe your pain?
ex. sharp, aching, burning, throbbing, dull

• PT interpretation of the possible pathology (hypothesis)

Question 22

Stage

Answer 22

1) Progression and Stability of the symptoms
- Improving
- Stable (staying the same)
- Unstable (worsening)

2) Time frame for injury or tissue healing

Question 23

Injury time frame

Answer 23

Acute 3 months

Question 24

Tissue healing time frame

Answer 24

Inflammatory 24-48hrs, up to 7-10 days
Proliferative 10 days - 6 wks
Remodeling 6 wks - 1 yr

Question 25

Main things found in Chart Review

Answer 25

Current conditions
General Demographics
PMH
Surgical History
Other clinical tests/findings
Social history
health habits
Living environment

Question 26

10 sections of medical chart

Answer 26

1) History & physical (H&P)
2) Progress notes (SOAP)
3) Physician orders
4) Nursing notes
5) Consultations
6) Lab results
7) Orders
8) Radiological studies
9) Administrative data
10) Discharge summary

Question 27

Interview chart

Answer 27

Patient rapport
Establish therapeutic relationship
Information and data… Is patient appropriate for PT