Unit 3: Chart Review in a Physical Disability Medical Setting

Question 1

The Medical Record

Answer 1

(or patient chart) provides the primary source of information about the client’s medical status. In the inpatient setting this may include

• Medical Record Information
• Current and New Medications
• Advance Directive

Question 2

Medical Record Information (medical record)

Answer 2

• Medical Record Number (patient identifier)
• Where and with whom the patient resides
• Date of birth
• Preferred Language
• Religious beliefs

Question 3

Advance directive (medical record)

Answer 3

A written statement of a person’s wishes regarding medical treatment. Typically made to ensure those wishes are carried out if the person is unable to communicate to the care team.

Question 4

Orders

Answer 4

• Written statements that dictate the patient’s medical plan of care.
• Often written by physicians, physician assistants or nurse practitioners.
• Includes medications, special tests & procedures, precautions, diet.
• Orders for interdisciplinary consultation (including OT).

Question 5

Post-surgical precautions

Answer 5

Movement precautions

• Limit ROM or positioning
• Cardiac precautions
• Keep vital signs within a specific range.

Question 6

Weight Bearing precautions

Answer 6

For example: non-weight bearing, partial weight bearing after injury or orthopedic surgery

Question 7

Infection control precautions:

Answer 7

Dictate the use of specific types of personal protective equipment.

Question 8

Neutropenic precautions (Infection Control Precautions)

Answer 8

Low white blood count or low platelets can put you at greater risk for infection.

Question 9

What are the types of precautions?

Answer 9

Post-surgical Precautions
Weight-Bearing Precautions
Infection Control Precautions
-Neutropenic Precautions
-Standard Precautions 
-Contact Precautions 
-Airborne Precautions

Question 10

Why do we need to understand normal laboratory values?

Answer 10

Activity may be contraindicated for values that are critically outside normal range

• Blood cell counts
• Arterial blood gases
• Basic metabolic panel
• Coagulation panels

Question 11

Imaging Reports

Answer 11

May indicate change in medical status especially concerning acute fractures, hemorrhagic events, embolic events, or evidence of metastatic disease.

• Computed tomography (CT) scan
• Magnetic Resonance Imaging (MRI)
• Ultrasound
• X-rays

Question 12

Computed Tomography (CT) Scan

Answer 12

Computer-processed combinations of many x-ray measurements taken from different angles to produce cross-sectional images.

Question 13

Magnetic Resonance Imaging (MRI)

Answer 13

Uses strong magnetic fields and radio waves to generate images of the organs in the body. Forms pictures of theanatomyand the physiological processes of the body.

Question 14

Ultrasound

Answer 14

Used to create images of soft tissue structures, such as the gallbladder, liver, kidneys, pancreas, bladder, and other organs and parts of the body. Canalso measure the flow of blood in the arteries todetectblockages.

Question 15

X-rays

Answer 15

May indicate a fracture or tear of a joint structure. Therefore, ROM or weightbearing may be contraindicated.

Question 16

Physician notes

Answer 16

• Provides day-to-day assessment of and plans for the patient’s hospital stay.
• Best practice is to review notes before any intervention.

Question 17

Interdisciplinary notes

Answer 17

• Ex. nursing, speech therapy, physical therapy, social work, case management.
• Additional objective findings on communication, mobility, responses to medications, concerns for patient family, discharge.

Question 18

Using Chart Review for Occupational Therapy Notes

Answer 18

Information from the chart review often will go into occupational therapy evaluation or treatment notes.

• History of Present Illness (HPI)
• Past Medical History (PMH)
• Social History or PLOF
• Changes in status since last OT intervention.

Question 19

History of Present Illness (HPI)

Answer 19

Why was the patient admitted to the hospital? What has happened since they arrived? What is their current medical status?

Question 20

Past Medical History (PMH)

Answer 20

Comorbidities or pre-existing conditions; past surgeries or hospitalizations.

Question 21

Social History or PLOF

Answer 21

Interdisciplinary notes may have information regarding patient support systems, where the patient lives, PLOF.