Intro to PTA Exam 1-3 Notes Flashcards
Note wrote in paragraph form and used to describe an encounter?
Narrative
Difficult to find a specific piece of information?
Narrative Note
Senstation: Pt. displays sharp/dull, proprioception, 7 kinesthesia to (B) LE from knees.
Objective
Performed all exercises today without any difficulty - can’t say tolerated treatment.
Assessment
ND - SNF (Skilled Nursing Facility) Ratios
1 PTA, 1 student, and 1 aide : 1 PT
ND Ratios
1 PT/2PTA
Littering
Criminal
PTA sues hopsital
Civil
Health Today
Presence of disease or injury, the resultant consequences on the body structures as well as the individual’s social, psychological, and physical functioning.
Tests/Measurements to Perform
Objective Section of initial evaluation/examination
Patient/Client Management Model PTA Documentation Responsibility
Intervention
Patient’s Goals
Subjective
PT’s Goals
Assessment
Third Party Payer
Insurance Company
Medicare
Federal - Parts B-C-D (optional)
Medicaid
State
5 Stages of Grief
Denial, Anger, Bargaining, Depression, Acceptance
Dx
Diagnosis (medical)
PT Dx
Physical therapy diagnosis
Subjective Information Examples
Opinion, Pt. Goals, Anything Pt. States, C/O (Complaints Of), Home-life (family/environment)
Objective Information Examples
Today’s Treatment,Measurements, Tests, Observations (Clinical), Pt. Education
Assessment Information Examples
Compare Progress(Beginning to Now) Interpret Data, PT’s Goals, Comments on treatment today, What does it mean?
Plan Information Examples
Written in furturistic terms. Planning for pt. treatment, session, PT consult.
ICD-9
Coding for classifying disease
ICF-World
International Classification of Function
Disablement
Relationship between body structures, ability to carry out tasks, and ability to function within society have become known as. Cannot do at all.
Impairment
Deviations from the normal.
Maintenance Therapy
Not Skilled, Not Physical Therapy.
POMR
Patient’s Problems
SOAP
Subjective, Objective, Assessment, Plan
Functional Outcomes Reporting
Focus on patient function
Templates & Fill-n Forms
Save time, minimize writing
Electronic Medical Record
Computer based documentation
Medicare Part A
SNF, Hospice, Home Health, In-patient hospital stays
Medicare Part B
Physician Services, Outpatient Services, DME (durable medical equipment) - walkers, bedsPT/OT (not covered by part A)
Medicare Part C
Medicare Advantage Plan - Run by private companies. Dental, vision, hearing
Medicare Part D
Prescription Drugs