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

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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
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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?
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4
Q

What is R in SBAR communication

A
  • R = recommendations
    request/recommend action
  • What is your suggestion/request? - Have relevant information available
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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
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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
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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
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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
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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
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