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
communication of home program intruction
- Review the program with the patient in the clinic.
- Provide clearly written instructions with pictures when necessary.
- Educate family members and caregivers as well
Procedure 1-3, p9
Confidentiality must be kept- ask patient if it is ok to share information with family and then ….
Educate the patient and family about treatment interventions
Goals of the treatment should be discussed and you should never what?
make guarantee statements about outcomes
How should you explain to pt and family
Speak in terms easy for the patient and family to understand
- Verbal
- Nonverbal
Table 1-5, p17
- Written
- Audio-visual
ways to communicate
Be aware of how a patient is reacting and adjust what you do
What are some barriers to effective communication?
Be careful with touch: should be therapeutic
Communication to patients with disabilities: determine what is needed
Box 1-7, p18
look up
- Errors can occur due to faulty medical equipment, cluttered environments, improper hygiene practices, etc.
- Instruct patient and family clearly
- Provide a safe environment
- Hand washing
- Keep area clear of clutter, cords, extra equipment
- Do not leave patients unattended
- Make sure everyone is well trained
- Document all occurrences and report them to a supervisor immediately
- Safety Recommendations- Box 1-10, p22
safety considerations
Safety Recommendations- Box 1-10, p22
look up
if it is not documented it…..?
It didn’t happen…..
where do you come in as a pta?
prodceudre 1-2, pll
- examin the pt medical recore
- examine the pt, gather sub and objective infor
- evaluate the infor and data
- postulate a lclinical diagnosis and prognosis bsed on results of the eval
- form a plan of care based onthe prognosis
- identify and select the intervention activities and tech
- establish the sequence, frequency, and duration of the plant
- consider termination of tx, including the development of a home tx
- implement the plan
- apply tech, activ, or procedurees
- revise or modiyf the plan dending of pt response
- evaluate the pts fuctional aciv to determine the need for further tx
- if appropriate, instruct famliy member or cargvier to provide time for them to practice
- provide a wriiteen HEP
where do you come in as a pta?
table 1-3, p14
- gather S and O
- observe the pt
- palpate pt areas
- test and measures
- cardiovacular/;ulmonary fx/fx ability and perforamn of daily tasks
- mental and cognitive fx review othe reports and tests when available
