Language of PT Flashcards
1
Q
What is the S in SBAR communication
A
S = situation
- A concise statement of the problem
- Identify yourself and where you are calling from
- Identify your patient and DOB and the reason for the call
2
Q
What is B in SBAR communication
A
- B = background
- Pertinent and brief information related to the situation
- Provide the relevant background, - PMH, supporting data; basics first, more depth as needed
3
Q
What is A in SBAR communication
A
- A = assessment
- Analysis and considerations of options
- What is your clinical assessment? - Do you have one?
4
Q
What is R in SBAR communication
A
- R = recommendations
request/recommend action - What is your suggestion/request? - Have relevant information available
5
Q
What are the elements of the first patient encounter and describe them
A
- Examination: obtained via subjective interview and hands on tests and measures
- Evaluation, referral/consult, diagnosis, prognosis: this is where the analysis of S and O are used to figure out what is going on
- Intervention: based on your findings, determine what you want to do - Plan (most often perform interventions on the first visit)
- Outcomes: reassess next visit/ongoing
6
Q
What is the first step in a patients first visit?
A
- interview/obtain history: types of data that may be generated from a patient or client history
- Can be obtained verbally from a patient or a HIPPA approved advocate, from an intake form, a chart or from another health care-professional
- Review of systems: getting information on each system/history
7
Q
Step 2: review of systems for first patient visit
A
- Simple screen of systems that we should be aware of in every patient
- Cardiopulmonary: the assessment of heart rate, RR, BP and edema
- Integumentary system: the assessment of pliability (texture), presence of scar formation, skin color, skin integrity etc
- Musculoskeletal: the assessment of gross symmetry, gross ROM, gross strength, heigh, and weight
- Neuromuscular: general assessment of gross coordination movement (eg, balance, gait, locomotion, transfers, transitions) and motor function (motor control and motor learning)
- Communication ability, affect, cognition, language and learning style: the assessment of the ability to make needs known, consciousness, orientation, expected emotional/behavioral responses, and learning preferences
8
Q
Step 3 of patient first visit:
A
- test and measure
- Cannot perform all of these what do we need for this patient based on what we know
9
Q
Step 4 of a patient’s first visit - Bridge to POC
A
- Interpret the individual’s response to tests and measures
- Integrate the test and measure data with other information collected during history
- Determine a diagnosis or diagnoses amenable to physical therapist management:
- Related to the impairment and functional limitation
- Determine a prognosis and include goals for physical therapy
- Develop interventions and POC