Quiz 1 Flashcards
What part of the medical management model is subjective information?
History taking portion of the examination
Who is patient data obtained from?
- Patient
- Patient medical record
- Patient family or caregiver
What type of information is patient data?
Subjective
What types of information is included in the subjective section?
- Patient’s current and past medical history
- Patient’s symptoms or complaints.
- Factors that impact the symptoms/complaints
- Patient’s prior level of function
- Patient’s lifestyle/occupation/societal roles
- patient’s goal
- medications
- other medical tests
What part of the medical management model is objective information?
examination process
What is objective data?
- data gathered through direct observation
- Gathered through methods that are reproducible
- Used as a reference for assessing outcomes
What does objective data include?
- data collection during system’s review and test and measures
- Interventions provided
- patient’s response to interventions provided
- Education provided to the patient
What type of information can be found in the assessment section?
- PT’s interpretation of S and O data (on overall summary of the patient)
- Goals
- Identification of impairment in body structures and functions
- the relationship between body structure and functional impairments and limitations in activities and participation
- PT diagnosis or PT Practice Patterns
- Prognosis/rehabilitation potential
- Justification for goals/treatment plan
- Explanation of any difficulties with obtaining S or O data
- Discussion of the patient’s other problems that can impact the patient’s physical or functioning or participation with a plan of care (comorbidities or complexities)
What type of information is in the plan section?
- Plan for intervention activities to occur: collaboration/communication, patient related education, procedural interventions
- Frequency and duration of therapy services
- Treatment progression
- Suggestions for further testing, treatment or referrals
- Plans for further assessment or reassessment
- Equipment needs
- Referral to other services
What is the first question a PTA should ask when reviewing the initial eval?
What interventions does the physical therapist want me to provide?
What questions should follow the first question when reviewing an initial eval?
- What problems is the intervention addressing?
- What is the pt’s current status regarding this condition?
- What are the PT and pt’s goals regarding this condition?
- What is the pt’s diagnosis?
- What is the pt’s prognosis?
What are the final two questions to ask when reading an initial eval note?
- Are there any contraindications or precautions I need to keep in mind as I work with the pt?
- Are there any other special issues I need to keep in mind as I work with this pt?
What are the four types of documentation?
- Narrative
- Problem Oriented Medical Record (POMR)
- SOAP
- Functional Outcomes Reproting
Where should info regarding the pt’s family go in SOAP and POMR format?
SOAP = subjective POMR = subjective data
Why do we document?
- Record pt data/care
- Demonstrate clinical decision making process.
- provide proof of medical necessity (“reasonable and necessary”)
- Provide proof of skilled care
- Provide evidence in the event of legal action
What qualities should your documentation have?
- accurate
- Complete
- legible
- clear
- concise
- thorough
What is skilled care verses maintenance care?
Skilled care = skills of a therapist are necessary to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation
Maintenance= can be done by an unlicensed person
What is activity limitation (ICF)?
difficulties that might be encountered by an individual who is attempting to complete a task or carry out an activity.
What is a participation restriction (ICF)
problems an individual might face while involved in life situations.
What is a disability (ICF)?
serves as an umbrella term for impairments activity limitations, and participation restrictions
