Unit 2 Study guide Flashcards
Principles of Documentation
- Doc every encounter
- Comply w/regulatory reqs
Id of pt and PT, PTA, SPTA where permitted - Pt full name and ID# on all official docs
- Indicate referral source
- Dated and signed
- Objective statements
- Complete statements
- Continuity w/progress notes
- At home plans should be well documented
- Informed consent
- Prompt and timely w entries
- Standardized abbreviations
- No empty lines/open spaces
- Outline before writing
- Properly countersign
4 sections of SOAP
S: subjective. Info from interview from pt, family, caregiver
O: information gathered from intervention.
A: of pt during and after treatment. Used to determine reimbursement. Include STOs.
P: what treatment is planned and its progression
Differentiate between initial note, progress note, and discharge note
- Initial: done by PT or other medical personnel.
- Progress (interim): written periodically. Includes daily visits, interventions, and reassessments. 3rd party payers require progress notes after every tx.
- Discharge note: written when tx is discontinued. Gives results of final exam and eval, goals achieved, and a summary of the intervention. Will give a recommendation by provider or d/c plan.
Principles of documentation
3 most important
Accuracy: true; objective, correct spelling and grammar.
Brevity: concise, to the point, no room for doubt.
Clarity: clear meaning, don’t shift tenses, legible.
Pt has good rehab potential
Assessment
Professional opinion
Hip clearing reproduces pain (L) knee
Objective
What PTA observed in tx
GT with crutches, 10% PWB RLE for 50 ft x2 w/min A x1
Objective
What was done in tx
Will initiate OT post-op per critical pathway.
Plan
(Look for will) something that needs to be done
States Hx of COPD since 2015
Objective
Look for reports, states, complains
Pt was difficult to assess due to lack of cooperation as demonstrated by closing his eyes and crossing arms when given a command.
Assessment
Says assess in it
Will be seen by PT as an OP beginning 3x/wk & progressing prn
Plan
Will
Past experience of PT for low back pain wo relief
Subjective
Rx this date: training in w/c propulsion & management, transfer training sliding board w/c mat & sitsupine. Pt required two rest breaks to complete all the activities.
Objective
Pt will demonstrate normal gait pattern within 2 wks to enable her to Amb for functional distances.
Assessment
STO
Pt reports pain (L) ankle while putting limited weight on LLE
Subjective
Pt. reported
Strength: 1/5 in (R) lower trapezius. (Ms strength is on a scale of 0-5)
Objective
Muscle tests, what was observed during tx
Talk to PT about progressing AROM exercises to PRE
Plan
What needs to be done, discussed
Inc AROM (R) shoulder to WNL writhing 2 wks to enable pt to reach items in overhead cabinets
Assessment
STO
Will inquire if Pt can be referred to a dietician
Plan
Pulsed US underwater at 1.5 W/cm2 to (R) wrist
Objective
What was done during tx
Pt will be (I) in donning/doffing prosthesis within 1 wk in order to stand
Assessment
STO
Pt states she lives w/husband in her own home
Subjective
Provide instruction to the pt in W/c management and propulsion
Plan
Needs to be done
Pt states he would like to return home with his wife following d/c
Subjective
Pt will perform lateral sitting transfer independently by next treatment in order to be independent in toileting
Assessment
Sto
Pt reported pain 6/10 pre-treatment and 4/10 post treatment
Subjective
Pt transferred from wc to mat with min a of one
Objective
Increased foot clearance during gait is due to improved LE strength.
Assessment
Baseline measurement such as Goni and MMt will always be included in:
Initial eval
Where do goals go in SOap
Assessment
To assist pt up in bed, PTA should position themselves
On patient’s affected side
PTA must have supervising PT approve and co-sign note?
No false
When segmentally moving pt in bed it’s important to begin with lower torso
False, begin at head
In a standing transfer the wc is generally placed
Parallel to bed
When operating a mechanical lift the patients buttocks should
Just barely clear the bed
When transferring a patient from bed to wc, the wc should be placed on the patients
Uninvolved/unaffected side
What transfer would you teach a pt who had an sci with paraplegia just 3 days ago.
Since pt has use of UEs, lateral sitting transfer with SB
If a pt is providing 50-75% of the work, how would you document assistance level?
Mod assist
To perform any lateral transfer w a SB your wc must have
Removable armrests
Physical requirement for lateral transfer w/o SB is UE strength
True
Functional outcome
Something pt will be able to do. To eat meal w family, to return to work, clear foot during gait
3 principles
Accuracy
True; objective; correct spelling and grammar
3 principles:
Brevity
Clear; concise. Give enough info to leave no doubt
3 principles:
Clarity
Meaning is immediately clear to reader
Don’t shift tenses
Legible handwriting
Identify content of POMR
Database: current/past info about pt
Problem List: problems treated by various practitioners
Identification of specific treatment plan by each provider on the case.
Assessment of effectiveness of treatment plan across time.
Identify between 4 sections of physical therapy note
S: subjective-information gathered from Pt during interview.
O: objective-information gathered during the intervention
A: assessment of pt during and after treatment. Used for reimbursement. Includes STOs
P: plan-what treatment is planned and its progression
Long term goal
- Correspond to problem list.
- States final status to be achieved by therapy.
- Written for extended time frames
- Help plan the treatment and guide the POC.
Short term goal
- Intermediate steps that lead to the LTG
- Task analysis
- Written in shorter time frames, 1-2 wks and direct treatment to specific needs and problems
6 criteria necessary to write an STO.
- Audience: who will exhibit the skill
- Behavior: what is the activity
- Condition: circumstances involved w behavior
- Degree: measurable portion
- Expected time: time to reach goal
- Function: what should they be able to do when goal is met
4 reasons to write goals
- Prioritize treatment
- Measure effectiveness of treatment
- Used to monitor cost-effectiveness
- Communication with other health professionals
Define teaching
To impart knowledge, skill or instruction. The act, practice or profession of a teacher; something taught, especially doctrine.
Define learning
The acquisition of knowledge or skills through experience, study, or by being taught.
Cognitive style
Preferred way an individual processes information. Styles describe a persons’s typical mode of thinking, remembering, or problem solving.
Learning style
Specifically deals with characteristics styles of learning and seem to be useful in terms of creating teacher awareness of individual differences in learning.
Transfer of learning
The ability to apply something learned in one situation to another setting. Defined operationally as improved performance on one task as a result of something acquired on a previous task.
Pedagogy
Method and practice of teaching, especially as an academic subject or theoretical concept.
Principles of pedagogy
Learning is:
•dependent upon capacities of the learner.
•A function of conditions of practice imposed.
•easily mastered when meaningful
•transfer is dependent upon similarities between tasks/work methods that can be applied
•Related to aspiration and experience
•Related to quality of motivation
•active participation is better than passive learning
•meaningful is more effective than rote memory.
Define androgogy
Method and practice of teaching adults
Principles of androgogy
Adults are:
•autonomous and self-directed
•bring established beliefs, values, opinions into learning environment
•goal oriented
•prefer relevant topics
•learn from mistakes but can be overly sensitive to failure
•like practical information
•favor different learning settings
•learn best when they succeed
•monitor own progress
•when what they learn is customized for them
•problem-centered in approaching learning
Extrovert
Try things out; focus on outer world
Introvert
Think things through; focus on world of ideas
Sensors
Practical; detail oriented; focus on facts and procedures
Intuitors
Imaginative, concept oriented, focus on meanings and possibilities
Thinkers
Skeptical; tend to make decisions based on logic and rules
Feelers
Appreciative; tend to make decisions based on personal and human considerations
Judgers
Set and follow agendas; seek closure even with incomplete data
Perceivers
Adapt to changing circumstances; resist closure to obtain more data
Felder-Silverman Style Model
Classifies students as: •Sensing/intuitive learners •visual/verbal •Indicative/Deductive •sequential/global
Sensing/Intuitive
- concrete, practical, oriented towards facts and procedures
* conceptual, innovative, oriented toward theories and meanings
Visual/Verbal
- prefer visual representations of presented material (pictures diagrams flow charts)
- prefer written/spoken explanations
Inductive/deductive
- prefer presentations that proceed from specific to general
* prefer presentations that go from general to specific
Active/reflective
- learn by trying, working w others
* learn by thinking things through, working alone
Sequential/global
- linear, orderly, learn in small steps
* holistic, systems learners, learn I large leaps
Kolb’s learning style model
Students have a preference for concrete experience or abstract conceptualization (how they take information in)
Active experimentation or reflective observation (how they internalize information)
Divergers
Why?
Explain how material related to their experience, interests, and future careers.
Instructor should be motivator
Strength: imaginative ability
Humanities/liberal arts, counsellors, developmental consultants, personnel managers
Assimilators
What? Info presented in logical, organized fashion with time for reflection Instructor should be expert Strength: create theoretical models Basic sciences and math
Convergers
How?
Work actively on well defined tasks. Trail and error and room to fail safely.
Instructor: coach, guided practice/feedback.
Strength: practical application of ideas
Physical sciences/engineering
Accommodators
What if?
Applying course material in new situations to solve real problems.
Instructor: stay out of the way.
Strength: doing things, carrying out plans, experiments.
Risk takers, more than other 3
Technical or practical oriented jobs, marketing/sales
Herman brain dominance
Classified students in terms of their relative preference for thinking in 4 modes based on task-specialized functioning of the physical brain.
Quadrant A
Left brain, cerebral
Logical, analytical, quantitative, factual, critical
Quadrant B
Left brain, limbic
Sequential, organized, planned, detailed, structured.
Quadrant C
Right brain, limbic
Emotional, interpersonal, sensory, kinesthetic, symbolic
Quadrant D
Right brain, cerebral
Visual, holistic, innovative
Multiple intelligence model
States there are 7 different ways of learning anything and are 7 intelligences.
7 intelligences
- Body/kinesthetic
- Interpersonal
- Intra-personal
- Logical/mathematical
- Musical/rhythmic
- Verbal/linguistic
- Visual/spatial
4 steps for effective instruction
- Preparation of learner
- Activity presentation
- Try out activity performance
- Follow up
Preparation of learner
- Build a rapport
- determine learners starting point
- make sure learner knows goal/objective.
- establish a learning environment
Activity presentation
- Clear oral instructions
- Demo provided
- Go step by step
Try out activity performance
- Allow learner to attempt task step by step.
- correct errors as they occur
- have learner explain the process
- repeat activity to develop motor skill.
Follow up
- Allow pt to work independently
- Assign a mentor
- check progress frequently
Strategies designed to foster adherence to an exercise program
- consider beliefs about exercising
- help identify benefits to sticking to exercise program
- explain rationale of each exercise/functional activity
- explain how specific exercises are designed to meet goals
- let pt have input. Selection, scheduling, and progression
- keep it brief
- ways to do exercise during every day tasks
- follow up to review/modify
- point out exercise related progress
- identify barriers/suggest solutions.
Define communication and its components
Exchange of ideas or information •messenger Message Receiver Feedback loop
Identify at least 5 ways to increase effectiveness of communication skills
- Reduce noise
- Get feedback
- Listen effectively
- Restate
- Be aware of body language
