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31 Cards in this Set
- Front
- Back
What are the elements of patient management?
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1. Examination
2. Evaluation 3. Diagnosis 4. Prognosis 5. Intervention |
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What is important to consider while taking a patient history?
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Medical chart
Patient interview Family interview Consultations |
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Which body systems are covered in a systems review?
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Cardiopulmonary
Integumentary Musculoskeletal Neuromuscular |
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What are different tests that are performed?
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Functional
Structural/Observation Movement Testing- Active, Passive, and Resisted Neurovascular Palpation Special Tests |
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What are essential parts to the prognosis?
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Level of improved function
Time needed Plan of Care Goals Outcomes Interventions |
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What are interventions?
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Skilled interaction of the physical therapist with the patient/ client
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What is the disablement model?
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Diagnose and manage movement dysfunction and enhance physical and functional abilities.
Focus on the impact of the condition on function Change the movement to improve function |
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What is the ICF?
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International Classification of Functioning, Disability and Health
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What are the components of ICF?
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Health Condition
Body Function (Impairment) Activities (Limitation) Participation (Restriction) Environmental Factors Personal Factors HIAPEP |
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What is impairment?
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Problems in body function or structure as a significant deviation or loss
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Activities limitation is defined at the level of the _______.
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person
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What is difficulty in the ability to perform an action task or activity in an efficient manner?
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Activity Limitation
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What are problems an individual may experience in involvement in life situations?
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Participation Restrictions
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What are the 3 parts to the examination?
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History
Systems Review Tests and Measures |
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What are the 5 parts to systems review?
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Communication
Cardiopulmonary Integumentary Neuromuscular Musculoskeletal |
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What is the primary purpose of history taking?
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Build rapport needed for a therapeutic relationship
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What is the secondary purpose of history taking?
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Collect Data
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When taking a history, you need to listen with your ear and ______.
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Eyes
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What types of questions are asked during the history?
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General --> specific
Clarifying |
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What are the 6 assessments in tests and measures?
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Functional
Structural Mobility Neurovascular Palpation Special Tests |
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When evaluating the LE, what do you look for?
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Standing Posture
LE Alignment Dynamic Construct |
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With PROM, what do high, medium, and low mean?
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High- Pain in mid-range
Medium- Pain at end range Low- Pain with overpressure |
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When assessing muscle length, what are key points to look at?
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Two joint muscles
Symmetry End-feels Relative Flexibility |
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When doing palpations, what are you looking for?
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Condition
Position Mobility |
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What are the W's of goal writing?
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WHO? patient is focus of goal
WILL do WHAT? -the activity the patient will perform under WHAT conditions? -address aspects of goal that are unique to patient. "across uneven grassy surfaces" or "with moderate wt-bearing" distance, time, etc. how WELL? -amt of assistance required to do it, how many attempts, ect by WHEN? -PT determines time frame. Based on healing times, research, experience, past progress |
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Medical Model
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Diagnose and treat the disease
Compare signs & symptoms of similar pathologies/diseases Treat the pathology |
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Disablement Model
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Diagnose and manage movement dysfunction and enhance physical and functional abilities.
Focus on the impact of the condition on function Change the movement to improve function (impair, act lim, partic rest) |
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documentation formats
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Narrative
SOAP Functional Outcome Report → more directive on outcomes and results. |
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SOAP notes
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Limitations: Dualism between subjective vs. objective, and terminology used.
Subjective Objective Assessment Plan |
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Functional Outcome Report → Recognize
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links between activities and participation!
Focus on performing functional activities Links to impairments and pathologies Various frameworks proposed (how we documented in ass#2&4) |
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Defensible Documentation
(where to go for info) |
APTA Website
Guidelines Billing Information Audit Checklists Case Samples |