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Define Documentation and what goes into it?
- any entry into the client record
- consultation report
- initial exam report
- progress note
- flowsheet/checklist
- should identify the care/service provided, re-eval, or summation of care (DC note)
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Reasons for documentation
- legal
- communication
- reimbursement
- quality assurance and improvement
- basis of DC planning
- organize thought process
- research
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What is authentication and the procedure?
- the process used to verify that an entry is complete, accurate, and final
- indications of authentications can include:
- --original written signatures
- --computer "signatures" on secured electronic record systems only
- signature with professional designation after it
- use official name or first initial
- cosignature for PTA
- meaning: agreeing with what is written
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Must haves for documentation
- patients full name
- must be dated
- providers full name and designation per signature (PT, PTA)
- documentation by graduates without unrestricted license must be cosigned
- documentation by students must be cosigned
- must be in black ink
- errors must have single line through it, initial and date
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Three types of notes
- initial note (all parts of a note)
- daily note/interim, or progress note
- discharge
- documentation is required at onset of each episode of care
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Documentation for an initial exam
- includes patient/client management process
- examination
- --chart review
- --systems review
- --interview
- --tests and measures
- evaluation
- diagnosis
- prognosis
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What content goes into a plan of care (POC)
- consistent with evaluation
- diagnosis
- long-term treatment goals
- type, amount duration, and frequency
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What goals go into a POC?
- long term
- short term
- format - ABCDT
- A: audience
- B: behavior
- C: conditions
- D: degree
- T: time
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Patient/client management guide notes
- history: problem, S in SOAP
- system review: part of O in SOAP
- tests and measures: part of O in SOAP
- evaluation: part of A in SOAP
- diagnosis: part of A in SOAP
- prognosis: part of A in SOAP
- POC: same as SOAP
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What goes in the subjective portion of a SOAP Note?
- document any statements or reports made by the patient, patients family, or caregiver
- details patients own perception of condition
- should not include extraneous info not related to patients current condition
- be careful not to pass judgement
- pain level
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What goes in the objective portion of a SOAP Note?
- patients progress towards functional goals
- provide details of interventions performed
- --location
- --frequency
- --intensity
- --duration
- --repetitions
- be specific and include enough detail regarding specific interventions
- observations
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What goes in the assessment portion of a SOAP Note?
- analysis of patients progress, including reasons why the patient is or is not improving as expected
- summarize patient progress and discuss factors hindering progress
- responses to interventions
- don't be vague
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What goes in the plan portion of a SOAP Note?
- interventions for upcoming sessions, including any change in intervention strategy
- don't be vague
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Documentation about intervention
- must be documented for every visit/encounter
- each visit must include:
- --patient/client self-report
- --specific intervention provided (including freq, intensity, duration)
- equipment provided
- changes in patient/client status as they relate to POC
- adverse reaction to interventions
- factors that modify the POC
- communication/consultation with providers or others
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What is a re-examination?
- done to evaluate progress
- must include parts of the patient/client management model
- --including parts of exam, eval, revised POC, and authentication
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What is a summary in documentation?
- must include the criteria for DC from PT
- current functional/physical status (current at DC)
- degree to which the outcomes and goals were achieved and reasons for not being acheived
- current physical/functional status
- must include the DC plan:
- --patient/family/caregiver education
- --HEP
- --referrals
- --recommended follow up PT care
- --equipment provided/ordered
- authentication
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PTAs and Documentation
- PTA should sign with "PTA" after name
- some states require PT to cosign note
- PT should be involved with planning care and DC planning delivered by PTA
- states vary on how to handle PTAs and documentation
- need to be comfortable with whats written by PTA before PT signs
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General Guidelines for Posititioning a Patient
- explain procedures to patients
- AMAP/ANAP
- maintain normal spine alignment
- use good body mechanics
- consider the environment
- provide a way for the patient to call for help
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What are the goals of short term positioning
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Checklist for short-term positioning
- patients safety
- good spinal alignment
- accessibility of necessary areas of the body
- trunk and extremities supported for comfort
- positioned well within the environment
- special needs accommadated
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Long term positioning safety and prevention
- safety:
- open airways
- avoid falls
- accomodate medical limitations
- prevention:
- prevent development of pressure ulcers
- contractures
- edema
- promote efficient function on body systems
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What increases the susceptability for pressure ulcers?
- decreased mobility
- fragile skin
- incontinence
- impaired sensation
- impaired cognition
- friction or shear
- impaired circulation
- cachexia
- muscle atrophy
- postural impairmentnutritional deficiencies
- meds affecting mobility
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What are the high risk areas for pressure ulcers?
- head
- shoulder blades
- elbows
- side of face
- buttocks
- heals
- knees
- tops of feet
- between knees
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How do you prevent pressure ulcers from forming?
- maximum of 2 hours in one position in bed
- maximum of 15 minutes in one position seatedreposition more frequently in patient has increased risk factors
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Describe pressure ulcers in terms of surface area, cushioning, and time
- decreased surface area, increased load
- decreased cushioning, increased load
- increased time, decreased pressure
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What is High fowlers position
- head of bed up
- knees of bed up/bent
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What is trendelenburg?
- bed flat
- head lower than feet
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How do you prevent contractures
- flexion (most common)
- may need to avoid positions of comfort
- L'nards
- multipodis
- --keep feet in neutral position
- --dont want plantar flexion
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How to prevent edema and cardiopulmonary complications?
- position distal extremities at or above heart level
- vary demands on heart by including more upright position
- vary positions to promote lung drainage
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What is the long-term positioning checklist
- clear airway
- good spinal alignment
- minimal gravity creating shearing forces
- cushioned support surfaces
- immovile extremities elevated
- joint and soft tissue contractures prevented
- trunk and extremities supported and stabilized
- long term functional positions
- positioned to optimize interactions with environment
- special needs accomodated
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Prone positioning
- full prone rarely used
- ensure clear airway and ability to call for help
- 3/4 supine and 3/4 prone are common variations
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Sidelying Positioning
- upper trunk typically rotated forward or backward
- use pillow or bolster to maintain upper trunk position
- elevate uppermost arm and hand
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Sitting Position
- increased frequency of repositioning
- may require small lumbar roll
- approx 90-90-90 position (hip, knee, ankle)
- avoid sacral sitting
- support arms
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Positioning Devices
- patients using positioning devices must still be repositioned
- frequently and monitored
- uses:
- reduce or eliminate load on tissues
- help patient maintain a static position
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Restraints
- use only when absolutely necessary
- use least restrictive device (LRD)
- fasten with quick release buckles or knots
- monitor patients closely
- must be ordered by MD
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Special positioning for THA
- avoid hip flexion beyond 60o to 90o
- avoid hip adduction past 0o
- avoid internal toration past 0o
- use abduction wedge
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Special Positioning for patients with CVA with hemiplagia
- prevent contractures
- prevent hand and wrist edema
- avoid distraction of hemiplegic shoulder
- supine: pillow under head, knees and affected arm
- sidelying: pillow under head, behind back, between knees, and arms hugging
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What are the common contractures?
- scapular retraction
- shoulder adduction, flexion, and internal rotation
- elbow, wrist, and finger flexion
- hip adduction, flexion, and IR
- knee flexion
- ankle plantar flexion
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Special Positioning of LE amputations
- Do's:
- keep hips in neutral rotation
- extend the knee
- minimum siting with flexed knee
- avoid pressure on nonhealed surgical site
- Don't:
- let residual limb hang off edge of bed
- place pillow under hip or knee while supine
- place pillow under back
- allow patient to lie with flexed knees
- aallow patient to cross legs
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General progressions of Bed Mobility
- abilities:
- stability precedes mobility
- maintaining precedes attaining
- large BoS precedes small BoS
- low CoG precedes high CoG
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Hook-lying
- bed mobility done in supine
- hips and knees are flexed
- its a component of bridging and rolling
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Bridging
- bed mobility done in supine
- lift hips and low back
- patient assists with upper extremities, not by pushing head into pillow
- clinician may stabilized at feet
- component of scooting and some ADLs
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