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190 Cards in this Set
- Front
- Back
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N
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normal
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NA
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not applicable, not available
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N/A
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applicable
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NAD
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no acute distress
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NDT
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neurodevelopmental treatment
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neg
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negative
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NG
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nasogastric
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NICU
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neonatal intensive care unit
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NKA
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no known allergy
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NKDA
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no known drug allergy
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NMES
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neuromuscular electrical stimulation
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NOS
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not otherwise specified
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NPO
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nothing by mouth
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NS
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no show, not seen
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NSAID
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nonsteroidal anti-inflammatory drug
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NSR
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normal sinus rhythm
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NWB
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non-weight bearing
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O
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objective, oriented
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oxygen
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O2
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OA
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osteoarthritis
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OB
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obstetrics
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OBS
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organic brain syndrome
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OCD
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obsessive compulsive disorder
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OOB
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out of bed
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OP
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outpatient
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OR
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operating room
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ORIF
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open reduction, internal rotation
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OT
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occupational therapist
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OTA
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occupational therapy assistant
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OTAS
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occupational therapy assistant student
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OTC
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over the counter
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OTR
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registered occupational therapist
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OX4
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oriented to time
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oz
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ounce
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-
p |
after
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P
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plan, posterior, pulse
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PA
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posterior, anterior; physician's assistant
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PADL
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personal activity of daily living
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PAM
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physical agent modalities
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PDD
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pervasive developmental disorder
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PE
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physical examination
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per.
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by
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peri.
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perineal
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PET
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positron emission tomography
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Ph. D
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doctor of philosophy
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PIP
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proximal interphalangeal
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PM
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afternoon, evening
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PMH
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past medical history
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PNF
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proprioceptive neuromuscular facilitation
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PNI
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peripheral nervous injury
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PNS
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peripheral nervous system
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POMR
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problem oriented medical record
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pos.
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positive
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post op
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postoperative
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PRE
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progressive resistive exercise
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pre op
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preoperative
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PRN
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as needed
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pro
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pronation
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PROM
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passive range of motion
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pt.
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patient
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PT
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physical therapy, physical therapist
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P/T
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part time
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PTA
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physical therapist assistant; prior to admission
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PTSD
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post-traumatic stress disorder
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PWB
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partial weight bearing
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Px
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physical examination
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qt.
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quart
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R
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right
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R
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respiration
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RA
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rheumatiod arthritis
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RBC
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red blood count
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R.D.
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registered dietician
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re:
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regarding
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rehab
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rehabilition
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reps
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repetitions
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resp
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respiratory
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RICE
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rest, ice, compression
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R. Ph
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registered pharmacist
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RLQ
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right lower quadrant
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R/O
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rule out
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ROM
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range of motion
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ROS
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review of symptoms
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R.T.
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respiratory therapist
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RTC
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return to clinic
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RTO
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return to office
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RUQ
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right upper quadrant
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RSD
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reflex sympathetic dystrophy
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Rx
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prescription
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S
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supervision
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-
s |
without
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S
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subjective
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SBA
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stand by assistance
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SCI
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spinal cord injury
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SH
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social history
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SI
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sensory integration
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SIDS
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sudden infant death syndrome
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Sig:
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instruction to patient
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SLE
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systemic lupus erythematosus
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SLP
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speech-language pathologist
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SOC
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start of care
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SOAP
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subjective, objective, assessment, plan
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SOB
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shortness of breath
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SNF
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skilled nursing facility
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S/P
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status post
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SSRI
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selective serotonin reuptake inhibitor
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STAT
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immediately
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STD
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sexually transmitted disease
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STG
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short-term goal
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STM
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short-term memory
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suppos
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suppository
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sup
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supination
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T
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temperature, Trace
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TB
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tuberculosis
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TBI
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traumatic brain injury
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TEDS
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thrombo-embolic disease stockings
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TENS
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transcutaneous electrical nerve stimulation
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TFCC
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triangular fibrocartilage complex
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ther ex
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therapeutic exercise
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THR
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total hip replacement
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TIA
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transient ischemic attack
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TKR
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total knee replacement
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TM(j)
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temporomandibular (joint)
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TNR
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tonic neck reflex
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t.o.
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telephone order
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TOS
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thoracic outlet syndrome
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TTWB
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toe touch weight bearing
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tx
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treatment; traction
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UA
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urinalysis
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UE
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upper extremity
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UMN
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upper motor neuron
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URI
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upper respiratory infection
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US
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ultrasound
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UTI
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urinary tract infection
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VC
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vital capacity
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VD
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venereal disease
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v.o.
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verbal orders
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vol.
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volume
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VS
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vital signs
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W
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watt
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WBC
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white blood count
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WBAT
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weight bearing as tolerated
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w/c
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wheelchair
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WDWN
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well developed, well nourished
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wk
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week
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WFL
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with functional limits
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wt
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weight
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x or X
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times
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y.o.
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year old
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yr
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year
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1o
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primary
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2o
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secondary
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Priniciples of bed or mat mobility
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must become indep in bed mob. to become indep w/ transfers
mat and bed skill level not necessarily the same thing |
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If having difficulty in bed mobility
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reduce friction
centralized weight reduce the effects of gravity have gravity assist |
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Transfer focus areas
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planning/preparation
precautions identify transfer priniciples types of transfers/techniques bed and mat mobility |
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safe transfers requires
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planning and organization before movement
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preparations for transfers
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review medical records
plan for assistanve level and precautions |
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questions to ask yourself
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what medical precautions?
preformed safely by one or assist required? enough time? does pt. understand? Are they afraid? Equip in good working order? |
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introduce yourself to patient, explain and
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have them repeat
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body positioning
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pelvic tilt
trunk aligment weight shifting lower extremity positioning upper extremity positioning positioning wheelchair |
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ADL goal
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client to achieve maximal level of independence according tothe person's performance skills
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OT practitioners do 4 things
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1. assess ADL/IADL performance skills
2. select treatment objectives 3. provide training or equipment/adaptive devices 4. reduce or eliminate barriers to performance |
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OTAs with proven...may function autonomously
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service competency
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ADL are oriented toward taking.....require basic skills
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care of own body
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IADL interacting environment
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requires more advanced problem solving skills
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Top down
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focus on occupation history and interest.
what can they do |
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bottom down
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focus on identifying problems in specific performance skills
what can they not do and how do we fix it |
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two different types of adaptive equipment
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high tech
low tech |
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what you must be able to do with adaptive equipment
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be familiar with commercial products
determine if modifications to commercial products is approp understand how the technology is applied, purpose, training needed recognize when assistive devices are not a good option |
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appliance
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provides benefits to the individual
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tool
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skill developmental
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minimal
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assists rather than replaces function
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maximal
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functional replacment
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custom
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designed just for the needs of the individual
more expensive |
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commercial
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faster
can be a mix-customized commercial product in clinic |
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process of providing technology
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1. evaluate client factors, context
2. evaluate technology available 3. recommend 4. Acquire |
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Technology: two roles
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1) helping-adaptive/assistive technology
2. teaching-rehabilitative/educational |
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Teaching ADL's
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1. reduce extraneous stimuli
2. demonstrate 3. have client do it 4. seek their feedback modify necessary 5. modify practice |
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hip precautions
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do not flex past 90 degress
do not adduct do not internally rotate |
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dressing-quadriplegia precautions
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autonomic dysreflexia
unstable spine pressure sores or skin breakdown uncontrolled muscle spasms less then 50% vital capacity dressing level determined |
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common equipment
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universal cuff
built up items spray can adapter electric shavers toothbrushes built up handles hands free hair dryer |
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purpose of documentation
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1. sequential and legal record
2. information about the client's care 3. facilitate communication w/ healthcare providers 4. reflect practitioner's reasoning 5. Justify need for OT treatment 6. Provider outcome data for tx, reimb, edu, and research |
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process- steps
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1. receipt of and clarification of initial referral
2. initial evaluation results 3. ongoing daily or weekly progress notes 4. discharge summary |
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legal aspects
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must know and meet state & federal laws
only acceptable of the treatment intervention |
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legal guidelines
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date all entries
document length, times, and tx codes document missed treatments document at the time of treatment increase accuracy |
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legal guidelines cont
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document specific facts
include supportive documents do not criticize another health care provider in the written record do not change after the fact w/o clarification |
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OTAs role
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screenings/evaluations
Coll. in preparation tx plan document progress tx plan revisions w/ reevaluation discharge summary in collaboration with OT |
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fundamental elements
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always sign note- initial/last name/credentials
mark out with one line/initial co-sign |
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quality of documentation
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well organized, concise
only pertinent information objective and accurate |
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quality of documentation
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1. insurance--payment
2. courts--litigation 3. other health care providers for communication 4. QA teams 5. Client |
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SOAP
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s= subjective-client views
o=objective-measureable, quantifiable and observable date a=assessment-therapist appraisal p=plan- plan for specific interventions |
