Lecture #4 (Examination and Assessment) Flashcards
How does a clinician know what deficiencies need to be addressed in a rehab patient?
An assessment examination
How should the goals be written?
To note that there is a plan in place to address the deficiencies noted in the exam
True or false:
It is always important to do a full exam with patients–whether or not they are acute or chronic.
False–acute patient may not be able to tolerate a full examination. Gather the information that you can without making them too painful, and then you can gather the rest later
What types of ROM should be documented in the exam? How should it be documented?
PROM, AROM, AAROM, and pain free ROM
**also flexibility if applicable, It should be documented by using a goniometer (degrees) or tape measure
How are joint mobs documentated?
4-5= hypermobile 3= normal mobility 1-2= hypomobile
What are other things that need to be documented on the exam in addition to ROM and flexiblity?
Joint laxity/mobility, special tests, muscle strength tests, and neurological tests
What will most likely be used to make RTP or release/discharge decisions?
Functional testing
What is the rehab diagnosis?
The problems identified in the exam (and final assessment( that need to be overcome in order to return a patient to their previous function
Is the patient progressing faster/slower than you anticipated? Is the patient motivated? Working hard? Is there a problem affecting other parts of rehab? Questions such as these are used to gauge what? Where would the answers to these questions be put in a SOAP note?
These are gauging progress and potential. They would be answered in the assessment (A) part of the SOAP note.
What should be included in the plan section of the SOAP note?
How the clinician will try to address the problemes noted in the assessment (the rehab diagnosis)
Do insurance companies like functional or non-functional goals better?
Functional–if a goal cannot be made functional, you need to question whether or not that goal is really needed. Also, a goal cannot be made unless a deficiency was noted in the exam
True or false:
At least 1/2 of rehab goals should be functional.
True!
True or false:
All LTGs should be functional.
True!
How often should goals be reassessed?
Every two weeks
How can we objectively measure strength?
MMT, dynometer, weight, body weight, functional, isokinetic dynomometer
How can we objectively measure ROM?
Goniometer, tape measure, inclinometer, joint play, percentage
When writing the plan for the treatment, what should the outline of the program include?
Frequency and duration of the treament, evolving as the patient status changes, address the goals of treatment, a and any home instructions/patient plan away from rehab
What would an assessment post-modality treatment be used to assess?
Patient’s pain level
What is the only way to make the program achieve its desired effect?
Constantly assess and change the program as needed on the info received during the assessment
As the program progresses, functional activities should be added in order to prepare the patient for what?
Their pending RTP. Functional testing should be sport specific and position specific. Specialized skills should also be addressed.
True or false:
You could be the best clinician in the world, but if you cannot document, you are unemployable
True
What is a document that accesses the progress of the patient and notes that all goals have been assessed why a patient is being released from the rehab program?
Discharge summary
Why is tracking data associated with a rehab program becoming increasingly necessary in this profession?
ATs can justify their ability to charge a third-party payors for thier services……also being used by insurance companies to curtail costs of rehab but still ensure good treatment is being given.
True or false:
ATs are above the curve in achieving good outcomes in less time
TRUE!!!!! :)
-We can push, motivate, etc. to progress the patient
