Unit 3: Chart Review in a Physical Disability Medical Setting Flashcards
The Medical Record
(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
Medical Record Information (medical record)
- Medical Record Number (patient identifier)
- Where and with whom the patient resides
- Date of birth
- Preferred Language
- Religious beliefs
Advance directive (medical record)
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.
Orders
- 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).
Post-surgical precautions
Movement precautions
- Limit ROM or positioning
- Cardiac precautions
- Keep vital signs within a specific range.
Weight Bearing precautions
For example: non-weight bearing, partial weight bearing after injury or orthopedic surgery
Infection control precautions:
Dictate the use of specific types of personal protective equipment.
Neutropenic precautions (Infection Control Precautions)
Low white blood count or low platelets can put you at greater risk for infection.
What are the types of precautions?
Post-surgical Precautions Weight-Bearing Precautions Infection Control Precautions -Neutropenic Precautions -Standard Precautions -Contact Precautions -Airborne Precautions
Why do we need to understand normal laboratory values?
Activity may be contraindicated for values that are critically outside normal range
- Blood cell counts
- Arterial blood gases
- Basic metabolic panel
- Coagulation panels
Imaging Reports
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
Computed Tomography (CT) Scan
Computer-processed combinations of many x-ray measurements taken from different angles to produce cross-sectional images.
Magnetic Resonance Imaging (MRI)
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.
Ultrasound
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.
X-rays
May indicate a fracture or tear of a joint structure. Therefore, ROM or weightbearing may be contraindicated.
Physician notes
- Provides day-to-day assessment of and plans for the patient’s hospital stay.
- Best practice is to review notes before any intervention.
Interdisciplinary notes
- Ex. nursing, speech therapy, physical therapy, social work, case management.
- Additional objective findings on communication, mobility, responses to medications, concerns for patient family, discharge.
Using Chart Review for Occupational Therapy Notes
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.
History of Present Illness (HPI)
Why was the patient admitted to the hospital? What has happened since they arrived? What is their current medical status?
Past Medical History (PMH)
Comorbidities or pre-existing conditions; past surgeries or hospitalizations.
Social History or PLOF
Interdisciplinary notes may have information regarding patient support systems, where the patient lives, PLOF.
