ICF/Chart Review/PT Interview Flashcards
What is the ICF model?
emphasizes components of health rather than consequences of diseases
participation rather than disability
role in society
environmental/personal factors
“whole person”
3 levels of human function:
body parts
whole person
whole person in their complete environment
ICF chart
Health Condition (disease/disorder)
- Body function/structure
- Activities
- Participation
- Environmental/Personal Factors
Body function/structure
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
Activity
execution of task/action
limitations are difficulties in executing tasks/activities
ex: walking, feeding, dressing, lifting ability, driving, sitting
Participation
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
Contextual factors
Environmental
Personal
Environmental
all aspects of external/extrinsic would that impact’s the person
ex: products/technology natural environment human made changes support/relationships services, systems, policies
Personal
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
Steps for patient-centered interview
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
Step 1) Setting the Stage
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
Step 2) Determine Agenda & CC
indicate time available
indicate our needs
obtain list of issues patient wants to discuss
summarize and finalize the agenda
Step 3) History of Present Illness, non-focused inquiry
Open ended beginning question, link to CC Nonverbal cues Physical characteristics Autonomic changes Environment Interviewer's own feelings
Step 4) History of Present Illness, focused inquiry
Symptom story
Personal story
Emotional story
Expand the story
Step 5) Transition to Clinician-Centered Interview
Give brief summary
Check accuracy
Indicate that both the content and style or inquiry will change if the patient is ready
Question sequencing
Choose questions based on info that is already gathered
Goals of patient interviewing
Rapport development
Determine of PT is appropriate
Establish therapeutic relationship
SINS
Severity
Irritability
Nature
Stage
Severity
Intensity of symptoms (How severe/intense?)
Limitation of patient’s activities (How much is this affecting?)
ex: mild, mod/severe
Irritability
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)
Nature
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)
Stage
1) Progression and Stability of the symptoms
- Improving
- Stable (staying the same)
- Unstable (worsening)
2) Time frame for injury or tissue healing
Injury time frame
Acute 3 months
Tissue healing time frame
Inflammatory 24-48hrs, up to 7-10 days
Proliferative 10 days - 6 wks
Remodeling 6 wks - 1 yr
Main things found in Chart Review
Current conditions General Demographics PMH Surgical History Other clinical tests/findings Social history health habits Living environment
10 sections of medical chart
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
Interview chart
Patient rapport
Establish therapeutic relationship
Information and data… Is patient appropriate for PT
