Information Gathering & Documentation Flashcards
Changes in body functions and structures are called…
Impairments
Changes in body function indicate
the magnitude/severity of impairment
Changes in body structure indicate
magnitude of impairment, nature of change and localization (the source)
Activity
the nature and extent of functioning at the level of the person
Basic Activities of Daily Living
related to activity; walking, dressing, eating, talking, learning etc.
Activity limitations
changes in activities due to a health condition, injury or disease
Participation
the nature and extent of a person’s involvement in life situations or social interactions within the context of their environment
Instrumental activities of daily living
related to participation; house/school work, play/leisure activities, parenting etc.
Participation restrictions
changes in participation due to a health condition, injury or disease
Contextual Factors
facilitators/barriers to activity - can be categorized as environmental or personal
Purpose of a Chart Review
To identify relevant information; enables us to uncover the client’s wishes and come up with goals for treatment
Modes of Information Gathering
Chart review, consultation with referring clinician or other HCP involved in the patient’s care, client interview
Steps to Creating a Problem List
- LIST problems from available information (via chart review, consultation or interview)
- CATEGORIZE problems based on ICF model
- IDENTIFY whether the problem is within/outside of scope of practice
Importance of Prioritization
to determine assessment or intervention needs, referral to other HCP, expectations for prognosis, support goal setting/communication with client
Purpose of Client Interview
establish subjective history, create problem list, define intervention goals, identify client wishes, communicate prognosis
