Management & Documentation Flashcards
what are team models?
Transdisciplinary
Interdisciplinary
Multidisciplinary
family and child make the decision- healthcare team is there to educate them on all of the options
documentation:
increased focus on documentation to meet medicare standards
documentation throughout episode of care is both a professional and legal requirement
thoughtful and thorough documentation will lead to improved quality of care
needs to reflect thought and decision making process of therapist
must include evidence of our unique body of knowledge
why is documentation important?
serves as a record of care
tool for planning and provision of service
way to communicate between providers
informs others of our unique body of knowledge
tells others of services we provide
examination:
document pertinent findings from patient’s:
- history
- systems review
- various tests and measures
- typically completed in one visit but may occur over more than one visit
- findings will be used to evaluate patient/client and determine diagnosis, prognosis, and plan of care
history:
chart review of past and current medical and social info
based on info gathered from chart review-deveolop set of questions for interview
always confirm info is correct
interview with parent/child:
use 2 identifies: child’s name and DOB
use observation skills to collect info
use the correct term for the dx
define terms in concrete ways
only state what you know to be true
get to know the child
ask the child what they like to be called- nicknames
discuss plan with both parents and child
respect their need for private space
show caring
allow parents positive hope for their child
inform parents of community resources
respect culturally based communication styles
ask the parents/child what are their goals
what to include in a pediatric history?
include mother’s pregnancy and complications
birth history
neonatal history
current health status
age when developmental milestones were achieved
social info on child and family
understanding of child/family attitude and knowledge related to dx
systems review:
cardiovascular/pulmonary system
integumentary system
MS system
communication system
pediatric systems review may also include consideration of child’s safety and well being, nutrition, behavior/attention and self determination
identify potential conditions that would require consultation with or referral to another provider
pediatric tests and measures:
related to body structure & function
related to participation & activity
developmental milestones transitional movements ROM Reflexes MMT tone posture extremity alignment gait sensory balance fitness level-endurance use of Ads pain mobility oral motor skills and feeding
hip extension ROM:
birth: 34.2 6 wk: 19 6 mo: 7 1 yr: 7 3 yr: 7 5 yr: 7
hip abduction in extension ROM:
birth: 55
1 yr: 59
3 yr: 59
5 yr: 54
hip adduction ROM:
birth: 6.4
1 yr: 30
3 yr: 31
5 yr: 24
hip ER in extension ROM:
birth: 90 6 wk: 48 6 mo: 53 1 yr: 58 3 yr: 56 5 yr: 39
hip IR in extension ROM:
birth: 33 6 wk: 24 6 mo: 24 1 yr: 38 3 yr: 39 5 yr: 34
pop angle ROM:
birth: 27 6 mo: 11 1 yr: 0 3 yr: 0 5 yr: 0
muscle tone:
what scales are used to assess muscle tone?
hypotonia–> normal –> hypertonia
Ashworth Scale
Tardieu scale
selective motor control scale
breaths/minute
0-1 mo: 35-55
up to 6 yrs: 20-30
6-10 years: 15-25
10-16 years: 12-30
HR (bpm)
0-1 month: 120-200
up to 3 years: 100-180
> 3 years: 70-150
systolic BP:
0-1 months: 60-90
up to 3 years: 75-130
> 3 years: 90-140
diastolic BP:
0-1 months: 30-60
up to 3 years: 45-90
> 3 years: 50-80
What is FLACC?
PAIN SCALE
FACE:
0: no particular expression or smile
1: occasional grimace or frown, withdrawn, disinterested
2: frequent to constant quivering chin, clenched jaw
LEGS:
0: normal position or relaxed
1: uneasy, restless, tense
2: kicking, or legs drawn up
ACTIVITY:
0: lying quietly, normal position, moves easily
1: squirming, shifting back & forth, tense
2: arched, rigid or jerking
CRY:
0: no cry (awake or asleep)
1: moans or whimpers; occasional complaint
2: crying steadily, screams/sobs, frequent complaints
CONSOLABILTY:
0: content, relaxed
1: reassured by occasional touching, hugging, or being talked to distractible
2: difficult to console or comfort
Wong-Baker Faces Rating Scale:
0= no hurt 1= hurts little bit 2= hurts little more 3= hurts even more 4= hurts whole lot 5= hurts worst
NPI:
0-10 numbers scale
visual analog scale
what is the purpose of standardized tests?
screening tool
determining a dx
facilitate planning of a tx program
help the parents understand the child’s limitations
ID areas that may need further evaluation
monitor progress and determine goal achievement
research
what are some pediatric assessment tools?
gross motor Functional Classification System
GMFM Gross Motor Functional Measure
Peabody Developmental Motor Scales- 2
Bruininks-Oseretsky Test of Motor Proficiency 2
Movement ABC 2
Alberta Infant Motor scales
Pediatric Berg balance scale
6 minute walk test
Evaluation:
synthesis of all the data and findings gathered from the examination
collaborative decision making with the patient/client
leads to documentation of impairments, activity limitations and participation restrictions
guides PT to dx and prognosis for each pt/client
International Classification of Functioning (ICF Model)
emphasizes “components of health” rather than “consequences of disease”
emphasizes participation rather than disability
part 1- body functions & structures, activities & participation
part 2- environmental & personal factors
diagnosis:
objective is to identify discrepancies that exist between the pt/client’s desired level of functioning and capacity of the patient/client to achieve that level
typically made at impairment, activity and participation levels
corresponding ICD code
prognosis:
conveys PT’s professional judgement for the pt’s/client’s predicted functional outcome
Based on EBP and experience
predict required duration of services needed to obtain desired outcome
rehabilitation prognosis vs. medical
recommended to consider prognosis for entire episode of care and not just specific time frame (during acute stay)
plan of care:
1- goals
2- statement of interventions/treatments to be provided during the episode of care
3- duration and frequency of service required to reach goals
4- anticipated discharge plan
5- birth to 3 can be embedded in their IFSP and school age (3-21) child in IEP
goals:
functional
measurable terms
predict level of improvement
made in collaboration with pt/client/family and in other appropriate team members
address impairments, activity limitations, participation restrictions and prevention
include anticipated timeframes
need to support medical necessity of the PT services
need to support for skilled intervention of PT or PA
focus for pediatric goals
promote independence
increase participation
facilitate motor development and function
improve strength
enhance learning opportunities
ease caregiving
promote health and wellness
therapeutic interventions:
developmental activities strengthening movement and mobility tone management motor learning balance and coordination aquatic therapy serial casting burn and wound care adaptive equipment/assistive technology safety awareness training & prevention programs caregiver assistance training cardiopulm/endurance training wheelchair mobility transfers gait orthotics/prosthetics ADLS-dressing and hygiene feeding recreation, play and leisure
play as treatment:
plan well be flexible use the environment let the child take the lead use music be aware of goals of other disciplines and incorporate them
discharge planning:
considered good practice to anticipate discharge planning from start of every episode of care
may be included in prognosis statement
peds- may include additional factors- transition planning from one program to another EI to school program
