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LAMP I > ICF model and Documentation > Flashcards

ICF model and Documentation Flashcards

1
Q

What are the subheadings in the patient/client management note?

A
  1. History
  2. Systems review
  3. Tests and measures
  4. Evaluation
  5. Diagnosis
  6. Prognosis
  7. Plan of care
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2
Q

What are the subheadings in the SOAP note?

A
  1. Subjective
  2. Objective
  3. Assessment
  4. Plan
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3
Q

Under the ICF what category would impairments be included in?

A

Body function and structures

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4
Q

Under the ICF what category would limitations be included in?

A

Activities

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5
Q

Under the ICF what category would restrictions be included in?

A

Participations

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6
Q

Under the ICF what category would barriers and facilitators be included in?

A

Environmental factors

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7
Q

physiological functions of body systems

A

Body functions

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8
Q

anatomical parts of the body

A

Body structures

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9
Q

execution of a task or action by an individual

A

Activity

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10
Q

involvement in a life situation

A

Participation

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11
Q

physical, social and attitudinal environment in which people live

A

Environmental factors

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12
Q

What does a guide to PT practice do?

A
  1. Describes physical therapist practice
  2. Standardizes terminology
  3. Delineates tests and measures and interventions
  4. *Delineates preferred patterns of practice
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13
Q

Name, in order, the 5 elements of patient/ client management

A

Start with the person:

  1. examination
  2. determine evaluation using education
  3. diagnose
  4. prognose
  5. interventions
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14
Q

What is included in the history section of the note?

A
  1. Demographic
  2. Current Conditions/Chief Concerns
  3. Prior/current Level of Function
  4. Patient Goals
  5. Social History
  6. Employment Status
  7. Physical Environment/ available resources
  8. General Health status
  9. Past/current social habits
  10. Growth and Development history
  11. Family Health History
  12. Current Medications
  13. Review of Systems** subjective info
  14. Diagnostic tests
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15
Q

What is included in the Review of Systems?

A
  1. General/constitutional
  2. Head, Eyes, Ears, Throat
  3. Cardiovascular
  4. Respiratory
  5. Gastrointestinal
  6. Genitourinary
  7. Musculoskeletal
  8. Integumentary/breasts
  9. Neurological
  10. Psychiatric
  11. Endocrine
  12. Hematologic/Lymphatic
  13. Allergic/Immunologic
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16
Q

What is included in Systems Review?

A
  1. Cardiovascular/Pulmonary
  2. Integumentary
  3. Musculoskeletal
  4. Neuromuscular
  5. Communication style/ Affect
  6. Cognition
  7. Learning barriers, preferences and needs
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17
Q

Helps determine conditions that may impact the chief complaint; Can identify conditions that require consultation with other providers; Can be completed in a relatively short time by experienced clinicians; Can determine further tests and measures

A

Systems review

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18
Q

This category contains HR, RR, BP, and edema (all completed in resting state).

A

CV/ Pulm

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19
Q

This category contains color, pliability, texture, continuity, and scars of skin.

A

Integumentary

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20
Q

This category contains gross symmetry/ ROM/ strength, and height/ weight.

A

Musculoskeletal

21
Q

This category contains gross coordinated movement (gait, balance, locomotion, transfers), gross motor function.

A

Neuromuscular

22
Q

This category contains age appropriate reactions, orientation and ability to make needs known.

A

Communication/ language and affect

23
Q

This category containsVision, hearing, reading level, and language

A

Learning style

24
Q

This category contains consciousness, orientation to person, place, and time

25
What does the tests and measures category include?
1. Pain 2. Strength 3. ROM 4. Balance 5. Transfers 6. Gait 7. Gross Motor Skill * *only tests related to the primary condition**
26
What is included in the S heading of the SOAP note?
History (chief complaint, prior level of function, meds, social hx, previous treatment review of systems)
27
What is included in the O heading of the SOAP note (in the correct order)?
Systems Review; Tests and Measures [d/c incl. summary of services)
28
What is included in the A heading of the SOAP note (in the correct order)?
Problem list, Evaluation/ Rationale, PT Diagnosis, Prognosis and goals [d/c note: progress on goals]
29
What is included in the P heading of the SOAP note?
Plan of care: Frequency/Intervention, types of intervention, equipment, education provided, additional plans for PT tests/ measurements, referrals made [d/c note: where they are d/c to]
30
A synthesis of all of the data and findings gathered from the examination; Collaborative decision making with the patient/client; Process leads to documentation of impairments or restrictions in body structure and function, activity, and participation as well as noting environmental factors and personal contexts; Guides the physical therapist to a diagnosis and prognosis for each patient/client
Evaluation
31
"Dec right shoulder AROM is preventing pt from reaching into overhead cabinets. This prevents pt from taking care of herself in her home." What is this an example of?
Justifying decisions
32
"Although amb is indep, pt’s progress toward indep transfers is slow but steady, possibly due to advanced age. Pt cont to need assist and will benefit from further PT to work toward index transfers." What is this an example of?
Justification for further PT
33
"Pt has become more dependent in transfers during the past 2 weeks secondary to inactivity associated with pt’s recent bout of pneumonia." What is this an example of?
Discussion of progress
34
"Although pt states entire left LE is so painful that it inhibits normal walking, pt amb over 500’ on treadmill FWB without assist device and without gait deviations" What is this an example of?
Inconsistencies
35
"Further testing of sensation and proprioception is needed and will be performed within 1 week." What is this an example of?
Further testing needed
36
"Exam revealed increased size of lymph nodes inferior to the left clavicle. Exam and eval by a physician is indicated. Pt referred to her primary care physician for medical exam and eval of left subclavicular area. What is this an example of?
Referral to another practitioner
37
describes impact that functional deficits or impairments have on the person’s ability to function in his/her environment
PT diagnosis
38
categories to describe medical signs and symptoms
Medical diagnosis
39
Requires informed clinical opinion; Justification for patient goals/ treatment plan; Clarification of a problem; Future services needed; Justification for further therapy
Prognosis (also includes revisions of prognosis, if applicable)
40
Help plan interventions; Set objective measures, to ensure progress with treatment ; Monitor effectiveness of interventions; Assist with justifying the need of skilled interventions; Communicacte the goals of PT to other healthcare professionals
Goals/ outcomes
41
What does the basic structure of a goal include?
Audience, Behavior, Condition, Degree OR WHO, while do WHAT by WHEN and HOW WELL
42
Setting type; Frequency; Anticipated length; Location of treatment; Bedside, department, aquatic, etc.); Interventions pt. will receive; Anticipated d/c location; Plans for further examination or re-examination; Any referrals; Patient/Family Ed; Equipment education or recommendation
Plan of care
43
What are some of the main reasons insurance will deny coverage?
1. Found data and research insufficient to identify conditions or diseases that justify waiving caps 2. Data do not capture clinical diagnosis for which therapy was received 3. Length of treatment for patients/clients with the same diagnosis varied widely
44
What are some other reasons insurance will not reimburse services?
``` 1. Poor legibility Incomplete documentation 2. No documentation for date of service 3. Documentation not understood due to abbreviations 4. Does not support the billing (coding) 5. Does not demonstrate skilled care 6. Does not support medical necessity 7. Does not demonstrate progress ```
45
Documentation required for every encounter; Support billing codes; Forms, checklists, flow sheets; May include goals
Tx/ Daily notes
46
Summarize patient’s response to Rx (progress); Measure progress toward goals; Frequency dependent on facility, insurance, patient’s progress
Progress/ Reevaluation notes
47
Completion of episode of care or prior to transfer to another setting
Discharge notes
48
What part of the note contains rationale/ recommendation for further medical evaluation?
Evaluation
49
In a d/c note, summary of services during the episode of care is in which section of the note?
Objective

LAMP I (2 decks)

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