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Pediatrics > Management & Documentation > Flashcards

Management & Documentation Flashcards

1
Q

what are team models?

A

Transdisciplinary
Interdisciplinary
Multidisciplinary

family and child make the decision- healthcare team is there to educate them on all of the options

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2
Q

documentation:

A

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

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3
Q

why is documentation important?

A

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

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4
Q

examination:

A

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
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5
Q

history:

A

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

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6
Q

interview with parent/child:

A

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

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7
Q

what to include in a pediatric history?

A

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

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8
Q

systems review:

A

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

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9
Q

pediatric tests and measures:

A

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
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10
Q

hip extension ROM:

A 
birth: 34.2
6 wk: 19
6 mo: 7
1 yr: 7
3 yr: 7
5 yr: 7
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11
Q

hip abduction in extension ROM:

A

birth: 55
1 yr: 59
3 yr: 59
5 yr: 54

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12
Q

hip adduction ROM:

A

birth: 6.4
1 yr: 30
3 yr: 31
5 yr: 24

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13
Q

hip ER in extension ROM:

A 
birth: 90
6 wk: 48
6 mo: 53
1 yr: 58
3 yr: 56
5 yr: 39
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14
Q

hip IR in extension ROM:

A 
birth: 33
6 wk: 24
6 mo: 24
1 yr: 38
3 yr: 39
5 yr: 34
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15
Q

pop angle ROM:

A 
birth: 27
6 mo: 11
1 yr: 0
3 yr: 0
5 yr: 0
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16
Q

muscle tone:

what scales are used to assess muscle tone?

A

hypotonia–> normal –> hypertonia

Ashworth Scale
Tardieu scale
selective motor control scale

17
Q

breaths/minute

A

0-1 mo: 35-55

up to 6 yrs: 20-30

6-10 years: 15-25

10-16 years: 12-30

18
Q

HR (bpm)

A

0-1 month: 120-200

up to 3 years: 100-180

> 3 years: 70-150

19
Q

systolic BP:

A

0-1 months: 60-90

up to 3 years: 75-130

> 3 years: 90-140

20
Q

diastolic BP:

A

0-1 months: 30-60

up to 3 years: 45-90

> 3 years: 50-80

21
Q

What is FLACC?

A

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

22
Q

Wong-Baker Faces Rating Scale:

A 
0= no hurt
1= hurts little bit
2= hurts little more
3= hurts even more
4= hurts whole lot
5= hurts worst
23
Q

NPI:

A

0-10 numbers scale

visual analog scale

24
Q

what is the purpose of standardized tests?

A

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

25
Q

what are some pediatric assessment tools?

A

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

26
Q

Evaluation:

A

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

27
Q

International Classification of Functioning (ICF Model)

A

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

28
Q

diagnosis:

A

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

29
Q

prognosis:

A

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)

30
Q

plan of care:

A

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

31
Q

goals:

A

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

32
Q

focus for pediatric goals

A

promote independence

increase participation

facilitate motor development and function

improve strength

enhance learning opportunities

ease caregiving

promote health and wellness

33
Q

therapeutic interventions:

A 
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
34
Q

play as treatment:

A 
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
35
Q

discharge planning:

A

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

Pediatrics (11 decks)

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