Foundations - Exam 2

  1. 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)
  2. Reasons for documentation
    • legal
    • communication
    • reimbursement
    • quality assurance and improvement
    • basis of DC planning
    • organize thought process
    • research
  3. 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
  4. 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
  5. 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
  6. Documentation for an initial exam
    • includes patient/client management process
    • examination
    • --chart review
    • --systems review
    • --interview
    • --tests and measures
    • evaluation
    • diagnosis
    • prognosis
  7. What content goes into a plan of care (POC)
    • consistent with evaluation
    • diagnosis
    • long-term treatment goals
    • type, amount duration, and frequency
  8. What goals go into a POC?
    • long term
    • short term
    • format - ABCDT
    • A: audience
    • B: behavior
    • C: conditions
    • D: degree
    • T: time
  9. 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
  10. 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
  11. 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
  12. 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
  13. What goes in the plan portion of a SOAP Note?
    • interventions for upcoming sessions, including any change in intervention strategy
    • don't be vague
  14. 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
  15. 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
  16. 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
  17. 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
  18. General Guidelines for Posititioning a Patient
    • explain procedures to patients
    • maintain normal spine alignment
    • use good body mechanics
    • consider the environment
    • provide a way for the patient to call for help
  19. What are the goals of short term positioning
    • safety
    • comfort
    • access
  20. 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
  21. 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
  22. 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
  23. What are the high risk areas for pressure ulcers?
    • head
    • shoulder blades
    • elbows
    • side of face
    • buttocks
    • heals
    • knees
    • tops of feet
    • between knees
  24. How do you prevent pressure ulcers from forming?
    • maximum of 2 hours in one position in bed
    • maximum of 15 minutes in one position seated
    • reposition more frequently in patient has increased risk factors
  25. Describe pressure ulcers in terms of surface area, cushioning, and time
    • decreased surface area, increased load
    • decreased cushioning, increased load
    • increased time, decreased pressure
  26. What is High fowlers position
    • head of bed up
    • knees of bed up/bent
  27. What is trendelenburg?
    • bed flat
    • head lower than feet
  28. 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
  29. 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
  30. 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
  31. 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
  32. Sidelying Positioning
    • upper trunk typically rotated forward or backward
    • use pillow or bolster to maintain upper trunk position
    • elevate uppermost arm and hand
  33. Sitting Position
    • increased frequency of repositioning
    • may require small lumbar roll
    • approx 90-90-90 position (hip, knee, ankle)
    • avoid sacral sitting
    • support arms
  34. 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
  35. 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
  36. Special positioning for THA
    • avoid hip flexion beyond 60o to 90o
    • avoid hip adduction past 0o
    • avoid internal toration past 0o
    • use abduction wedge
  37. 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
  38. 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
  39. 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
  40. General progressions of Bed Mobility
    • abilities:
    • stability precedes mobility
    • maintaining precedes attaining
    • large BoS precedes small BoS
    • low CoG precedes high CoG
  41. Hook-lying
    • bed mobility done in supine
    • hips and knees are flexed
    • its a component of bridging and rolling
  42. 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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Foundations - Exam 2