PT. Assess Exam Review 2 Flashcards
What is HIPAA?
–Only approve health care providers can have access to PHI
–legal obligations regarding patient information are specified under privacy and security rules
What does HIPAA stand for
–Health Insurance Portability and Accountability Act
Where is it appropriate to discuss patient information with other therapists?
–Workstations so that the screens are not visible to prying eyes
–only access the information needed to perform the job
–only with other members of the health care team who need to know such information and only in a private area where visitors are not allowed
What patient information can you post on social media
–none and never
How does Culture affect the interaction between therapist and patient
–failure can encounter in patient dissatisfaction, poor adherence to treatment regimens, and unsatisfactory health outcome
–be self-aware, do not let your emotions get in the way of do the patients wishes
–adapt communication with the patient and family beliefs
–modify to accommodate
How does Learning Levels affect the interaction between therapist and patient
–emphasize oral instructions vs written instructions
–adjust language level to appropriate
–provide written materials at 5th to 8th grade level
How does Sex affect the interaction between therapist and patient
–
How does Age (younger child) affect the interaction between therapist and patient
–keep teaching/learning episode short
–use fun and game approach
–enlist family assistance
How does Language Barrier affect the interaction between therapist and patient
–enlist family assistance
–secure translator
–use an approve translation service
How does Hearing affect the interaction between therapist and patient
– speak slowly and clearly while facing the patient
–have patient use hearing aid
–emphasize visualization and touch
–enlist family assistance
what is the teach back method
–being able to explain to the patient on how a device should be use
–seeing the patient is using the device correctly before leaving them
–have the patient repeat in their own words the information you are trying to communicate
What is SMART stand for
–S: specific
–M: Measurable
–A: action oriented
–R: realistic
–T: time
What are SMART goals
–written action plan are particularly useful for involving patients in goal-setting, and self-care activities
When should you use SMART goals
–exactly what is the goal
–how will the goal be achieved
–what barriers might prevent achieving the goal
–how can barriers be overcome
–by what mechanism will follow-up occur
–how much confidence does the patient have in achieving the goal
What does SBAR stand for
–S: situation
–B: background
–A: assessment
–R: recommendation
When is SBAR used
–coordinate patient handoffs, giving short but precise essential information needed by the shift change RT
–when making recommendations to the patients’ physicians for a change in therapy or when documenting a patient encounter in the medical record
–schedule procedures at times least likely to conflict with other essential patient activity and most likely to coincide with any relevant drug
What has to happen for communication to be effective
– healthcare provider should listen to the Pt
–project undivided interest in the patient
–introduce yourself in a professional manner
–respect the patient’s beliefs and attitudes
–use a relaxed conversational style that communicates empathy and genuine concern
–open ended questions
What is a Chief Complaint
–a brief notation explaining why the patient is seeking medical care
–open-ended question
How do you calculate pack years
– is the number of years the patient has smoked multiplied by the number of packs per day
What are Signs
–objective
–measurable
–assessed values
–example: HR, BP, RR
What are Symptoms
–Subjective
–Description of onset: date, time, and type
-patient description
–Setting: cause, circumstance, or activity surrounding onset
-measured by patient perception
–Location: where on the body the problem is located and whether it radiates
–Severity: how bad it is and how it affects activities of daily living
–Quantity: how much, how large an area, or how many
–Quality: what is like and character or unique properties such as: color, texture, odor, composition, sharp, viselike, or throbbing
–Frequency: how often it occurs
–Duration: how long it lasts and whether it is constant or intermittent
–Course: is it getting better, worse, or staying the same
–Associated symptoms: symptoms from the same body system or other systems that occur before, with, or following the problem
–Aggravating Factors: things that make it worse
–Alleviating factors: things that make it better
example: pain, shortness of breath, cough
What is a fever a sign of
–infection
–other problems
What are the Progress Notes in the chart
–when the physician interviews and examines the patient to identify the patient’s progress and response to treatment
–other healthcare providers will document progress notes in the chart
What information are charted
-Admitting information
–written by the attending physician
–description of important facts related to the patient’s admission
-History and assessment notes
-Laboratory tests
-Imaging Studies
–symptoms
–vitals
–assessment
–planning
Who uses the Progress notes the most
–Are notes by the physician and other healthcare providers each day
–describes the patient’s response to the treatment
–RT/ nurses
What is DNR statues
– a legal document in which a person specifies that actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity
–Do Not Attempt to Resuscitate
–DO Not Resuscitate
How does DNR change patient care
–instituted based on patient/family wishes and physician order
–be aware of variations and specific instructions
–resuscitation should not be attempted
What is a Cough
–one of the most common symptoms seen in patients with pulmonary disease
–Protective reflex
What steps are involved in a Cough
–Inspiratory
–Compression
–Expiratory
What are the common causes for a chronic cough
–persistent
–Last more than 3 weeks
-Causes:
–Postnasal drip ( most common)
–Asthma
–COPD exacerbation
–Allergic rhinitis
–GERD
–Chronic Bronchitis
–Bronchiectasis
–Left heart Failure
–CHF
What are some of the possible complications associated with coughing
–Torn chest muscle
–Rib fractures
–disruption of surgical wounds
–Pneumothorax or pneumomediastinum
–Syncope
–Arrhythmia
–Esophageal rupture
–Urinary incontinence
