PREP FOR Pt CARE AND ACTIVITIES Flashcards
OBJECTIVES
- Discuss the concepts of collaboration, cultural diversity and communication as it relates to patient care and management.
- Discuss and implement safety considerations before, during and after physical therapy treatment.
- Describe the major components of the patient management process
- Describe the major components of a written home program
FYI
Collaboration getting ready for pt care
what are some types of Teamwork?
- Interprofessional collaboration
- Professional collaboration
type of teamwork that is Patient centered versus profession centered
Interprofessional collaboration
what type of teamwork? -
- Co-treatment (more than likely OT)
- PT-PTA relationship
Professional collaboration
take a look
Patient orientation- procedure 1-1, p4
- introduce
- verify pt your treating
- verify or confirm pt info you have recieved(name diagnosis, purpose of tx and referral)
- interview the pt to obtain relevant info (be alert of culture)
- perform assesment, exam, and eval aciviities to establish the pts capabilities, condition.probs, needs, goals, and diagnosis
- establish tx goals and functional outcomes with pt input
- inform the pt of the tx plan and technique: include info about risk or adverse effects
- encourage the pt to ask questions to enable the person to consent to or decline tx
- request that the pt sign an informed consent document or record teh oral cnsent in the medical record
Preparation includes a thorough review of the patient’s what?
- medical record
- past treatment notes
Definition
“Differences in race, ethnicity, language , nationality or religion among various groups within a community, organization or nation.”
cultural diversity and awareness
Cultural divesity may affect many thing such as…..
- Actions
- Customs
- Beliefs
- Values
Persons who are culturally diverse are protected by the
ADA of 1990
Identifying cultural norms and traditions will allow you to ?
- communicate more effectively with the patient
- improve patient satisfaction
- At time of registration
- Verbal consent before treatment interventions
- Not of legal age of consent (18), mentally confused or incompetent- consent given by parent, guardian, POA, court-appointed advocate or surrogate
Informed consent
What are the elements of informed consent?
Box 1-2, p7
- description of the pts condition, diagnosis or evaluative data and info
- description or outline tothe proposed, recommended tx plan, tech, or procedures.
- primary, known, anticipated, or potential risks, complication and precautions associated iwth the proposed tx
- expected prognosis or outcome of the proposedtx without a stared implied guarantee to results
- alternative forms of tx appropriate for the persn’s condition with potential risks, complications, and precatuinons and the expected prognossis
- quesitons from the pt and responses from caregvir that are thorough and honest
- explain the potential or possible consequence of no tx if the pt refuses tx
- document that you proviede an opportunity for informed consent before initiation of tx and the pt decision to consent ot or refuse tx
Why is documentation so important????
- Guide and change treatment
- Communicate to the whole team- Continuity of Care!!
- Someone else can take over treatment
- Payment
what type of documenting:
- Includes patient problems, initial, interim and discharge notes
- Improves communication which may improve quality of care. Includes the use of SOAP format.
- What are the four phases of POMR?
- p8
POMR- Problem-oriented medical record
documentation reminders
- PT Examination and Evaluation
- Diagnosis
- PT diagnosis
- Prognosis and Plan of Care
- Short term and long term goals
- Interventions
- Should be agreed upon by therapist and patient
SOAP format
Phys Rehab p19-20