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  1. What is Physical Therapy?
    a health care profession that emphasizes the science of pathokinesiology and application of therapeutic exercises and other techniques for the prevention and treatment if disorders of human motion to restore/maintain function.

    We primarily use exercises to treat movement disorders.
  2. How did PT and APTA come about?
    WWI -injured soldiers and Polio with kids. PT was in demand. MDs went to Europe to learn therapeutic techniques; then taught to (female) nurses who treated injured soldiers and Polio victims. They were later called Reconstruction Aides. In 1921 New York American Women's Physical Therapeutic Association was establish to share information and set standards.
  3. Who is Mary McMillan?
    She was a Reconstruction Aide at Walter Reed Hospital in DC during WWI. Appointed head Rec. Aide in 1918. First president of AWPTA in 1921. She was credited as the first PT. In 1940's, Physical Medicine became a medical specialty
  4. What's the purpose of APTA?
    *communication with profession and fellowship * relations with the public and other health care professions *standardize and improves PT education *establish practice standards *monitor legal issues, take action *continuing education *sponsor research, give grants, loans *provide publications
  5. What happened in 40’s, 50’s, 60’s?
    o   1947: APA renamed APTA, membership 8000

    o   1960 – APTA declare education level to be Bachelors degree

    o   1960s  - First PTA program established to accommodate needs --> Membership 15,000 (Associates Degree)
  6. What happened in 70’s, 80’s, 90’s?
    o   1980’s – APTA (not AMA) became sole accrediting agency for PT programs --> PT was now an independent profession --> APTA membership ~ 40k

    o   1990’s – membership ~75k -->Profession struggled with Balanced Budget Act in late 90’s
  7. What's the purpose of APTA?
    • o   Communication within profession,
    • fellowship
    • o   Relations with the public and other
    • health care professions
    • o   Standardizes and improves PT education
    • o   Establish practice standards
    • o   Monitor legal issues, takes action
    • o   Continuing education
    • o   Sponsor research, give grants, loans
    • o   Provide publications
  8. What's the purpose of PT Board of CA?
    o   Part of CA Dept. Consumer Affairs (state govern agency)

    • o   Purpose is to protect publicly by:
    • Making the PT Law, PT Practice Act, under Medical Practice Act; Administer PT/PTA board exams; Licensing PT’s and PTA’s
    • ; Investigating complaints and taking disciplinary action
  9. What's the purpose of The Federation of State
    Boards of Physical Therapy?
    o   Federation of State Board of PT

    • o   Develops and administers the National PT
    • Exam (NPTE) for both PTs and PTAs in all states

    o   Standardizes entry level competence
  10. What's the purpose of Commission on Accreditation in PT Education?
    o   Accrediting agency for PT/PTA programs

    o   Recognized by U.S. Department of Education

    o   19 members, educators, PT practitioners, college administrators, public citizen

    • o   Bases judgments on APTA standards and
    • others
  11. PT must...
    ...see patient first

    o   Do exam and evaluation

    • o   Document diagnosis, prognosis,
    • intervention

    o   Establish a treatment plan a.k.a “plan of care” (and do any later modifications)

    o   *****The PT who does the evaluation is the “PT OF RECORD”

    Later do re-eval as needed and D/C summary
  12. PT Supervision of PTA
    o   PT provides supervision and direction to PTA to ensure that PTA does not function autonomously

    o   PT must follow patients progress

    • o   PTA must be able to identify and
    • communicate (via phone calls or texts with immediate response) with PT during treatment

    o   PTA must document and notify PT of changes in patients condition
  13. The PTA shall not…
    o   Do anything before PT has evaluated patient

    o   Document evaluation or re-evals

    o   Write D/C Summary

    o   Establish or change plan or care

    o   Write progress reports to others

    o   Solely represent PT in patient care meetings (2 can go but 1 must be a PT)

    o   Supervise aides

    o   Treat patients if PTA is in management

    o   *************PT can leave if PTA is treating*************

    o   ******PT must ALWAYS be on site if aide is helping*******
  14. PT supervision of PT Aide
    o   PT must document aide’s competency; PT must sign off for each aide’s competency

    o   PT delegates only appropriate tasks to aide

    o   PT must be in same facility as and in immediate proximity to aide

    o   PT must provide direct service to patient on same day

    o   PT must document aide’s treatment (implemented in 2011)

    o   *****Exam Questions listen to recording 18mins*******

    o   *****Exam Questions listen to recording 30-33mins Supervision in CA*****
  15. Supervision of PTA student
    o   PT must supervise PTA student on site if you are a student

    o   Clinical instructor may be a PT or PTA (CI trains you on the job)

    o   PTA student must document and sign chart notes

    o   CI must cosign students notes on same day

    • o   Supervising PT must have/document weekly
    • patient case conference with student
  16. Know The Parties
    o   1st party = consumer / patient

    • o   2nd party = health care
    • provider (e.g. physician, clinic, hospital, PT,…)

    • o   3rd party = payer (e.g.
    • insurance company, employer, medicare, i.e. the guys with the $$$
  17. Common Payment Approaches
    o   Individuals or employees pay monthly premium to health insurance companies in exchange for coverage

    • o   Cost Based Reimbursement = Payer is totally responsible for paying the cost of services, usually as determined by
    • the provider

    o   Managed Care = Reimbursement amounts are negotiated; not necessarily what the services actually cost;  *****this is mostly used now*****
  18. Manage Care Definition
    o   A healthcare payment system where the 3rd party payer has increased control over the cost and utilization of health care services

    • o   Therefore neither the providers nor consumers have as much control as they would under a cost-based reimbursement
    • system
  19. Managed Care Structures
    o   Deductibles

    o   Co-payment

    --> HMO= Health Maintenance Organization Utilizes primary care physicians (PCA) as “gate keepers”· HMO assumes responsibility for cost and quality of care· Therefore choices of providers are limited

    • --> PPO= Preferred Provider Organization·      
    • Network of providers who offer discounted rates and assume responsibility· Providers then hope to receive increased business. Not like to require PCP referral for services

    --> Capitation (System) -  Providers are paid up front for services

    • -->Consumer-driven health care· Consumers utilize pre-tax health saving accounts (HSA’s or FSA’s) to pay for services;
    • deductibles are usually higher
  20. Government Health Care Payment Systems  (Programs = 3rd party payers = the government)
    o   Medicare (Parts A,B,C,D) - Federal government program Pays for healthcare for those over 65 Managed by CMS (Centers of Medicare and Medicaid)

    o   Medicaid (aka  Medi-Cal here in California)

    -->Is a state level program; state may opt in or out

    • -->Pay for health care for low-income or disabled, under 65·      
    • ****for people who have the least amount of money; if you’re poor and low-income, you can apply but reimburse is low thus treatment is not of quality·      
    • ****most County hospitals will take MediCal
  21. Affordable Care Act
    o   Full Implementation in 2014

    o   Requires most America to health insurance (some exemptions)

    o   Establishes “market plans” to buy insurance

    o   Offers coverage separate from employment

    o   These plans must offer “essential benefits” (10 items listen Time 58mins)

    o   No discrimination for pre-existing conditions

    o   No annual/lifetime caps on coverage
  22. Balanced Budget Act 1997
    o   Passed to decrease Federal Budget deficit

    o   Resulted in major cuts to Medicare (and other government agencies)

    o   Prompted Medicare to introduce Prospective Payment System (PPS) replacing previous cost-based reimbursement system

    • § Patient are categorized as DRG’s or RUG’s ·      
    • Diagnostic Related Group·      
    • Resource Utilization Group

    § Providers are paid at pre-set rate for each category
  23. PT practice has changed in response  to managed care and PPS
    o  Decrease reimbursement requires:

    § Better case management skills

    § Better time management skills

    § Better documentation skills, to demonstrate accountability

    § Less 1-on-1 treatment and greater reliance on patient follow-through

    § Smarter use of PTA’s and Aide’s
  24. What Cobra and Wokers Compensation?
    • o   COBRA (Consolidated Omnibus
    • Reconciliation Act): law requiring employers to allow employees to stay w/ their group insurance after job loss

    o   Workers Compensation: Legislation providing income, medical expenses to workers injured on the job. Insurance provided by employers
  25. Other acronyms to know
    o   PTIP – Medicare definition for Private PT Practice

    o   CORF – Medical definition for comprehensive outpatient rehab facility

    • o   QA, UR – internal quality management
    • process for health care providers/facilities

    o   HIPAA – 1996 Congressional Act which ensures continuing health care coverage when changing employers and confidentiality of private information

    o   JCAHO – independent accrediting agency
  26. Informed Consent
    o   Patient has the right to consent to or refuse treatment

    o   Patient must be competent

    o   We must inform patient of treatment, including risks, benefits, alternative Rx’s, before proceeding

    o   We must document the patients consent
  27. Evidence-Based Therapy
    Therapy which has benefits backed by research; instead of personal experience or intuition
  28. Direct Access
    o   Patients are allowed by law to seek and receive treatment by a PT in California without a physician’s referral

    o   Insurance may not pay for it, however without MD referral
  29. Patient’s Right
    § Right to refuse Rx’s

    § Right to informed consent

    § Right to access medical records

    § Right to confidentiality
  30. Advanced Directive (living will)
    • o   Written/recorded instructions provided by an individual regarding their health care in the event they are unable to
    • communicate or make decisions.
  31. DNR = Do Not Resuscitate
    o   POLST = Physician Orders for Life Sustaining Treatment – used in emergency situations; 3 types of levels
  32. HIPAA and Confidentiality
    o   Definition: keeping patient health care and personal info private

    o   PHI – Protected Health Information

    o   Required by law and ethics
  33. Cultural and Religious Sensitivity
    o   Definition – Being aware of and open to difference between cultures or religious

    o   Respect and respond to these differences
  34. Cultural Competence
    o   Definition – the ability to function effectively with and meet the needs of diverse patient populations

    o   Goal – to close the disparities in health care, per U.S. Office of Minority Health (under HHS)

    o   Think of cultural competence as a clinical skill that can lead to more effective care

    o   Don’t stereotype!
  35. What can you do to demonstrate cultural competence?
    o   Identify / document communication strategies:

    § Identify patients native language and provide educational material in that language

    § Utilize professional interpreters

    o   Identify modesty issues

    o   Identify gender issues

    o   Work with patients families

    o   Identify special garments/items to be worn

    o   Watch carefully for any signs of pain

    • o   Identify possible cultural biases at your
    • facility/department

    o   Ask non-judgmental questions

    o   Try to accommodate as able and as is reasonable
  36. Impairment
    • o   Definition = abnormality of an
    • anatomical  structure, specific
    • organ or system (e.g. osteoarthritis/ TKA, with decreased quad strength)
  37. Functional Limitation
    o   Definition = Limitations on performing ADL’s competently or as expected (e.g. transfers stairs, grooming
  38. Disability
    o   Definition = Inability to perform a normal range/collection of ADL’s expected in specific roles (e.g. play sports, go to work, care for kids)
  39. American with Disabilities Act
    • o   Civil Right Law which prohibits
    • discrimination based on disability

    • o   Congressional act signed into lay in
    • 1990’s since revised

    o   Established standards for accessibility
  40. Define Medical Diagnosis
    o   Definition = (Recognition of) pathology or etiology (e.g. MS, Fx, Sprain, HNP, CVA)

    o   Determined by the MD, frequently by using diagnostic procedures of equipment
  41. Define PT Problem (aka PT Diagnosis or Dx)
    • o   Definition = (Identification of)
    • pathokinesiologic problem stemming from the medical Dx and the corresponding
    • functional limitation

    o   Identified using tools within PT’s scope of practice
  42. Why do we document?
    o   Record and Evidence of Care for…

    § Communication with staff

    § Legal issues and actions (i.e. charts are a legal document)

    § Quality Assurance

    o   Reimbursement is based on documentation

    § Must demonstrate accountability to payer (i.e. must show SKILLED NEED and reasonable progress toward goals
  43. What do we document in PT?
    o   Dx and PT problem (evaluation).......done by PT

    o   Treatment plan (eval).......done by PT

    o   Goals or desired documents (eval).......done by PT

    o   Subjective and Objective data......done by PT & PTA

    o   Response to Rx, effectiveness of PT........done by PT/PTA

    o   Discharge summary........done by PT

    o   Consent to Rx........done by PT

    o   Record of treatment à done by PT/PTA (if aide is treating then PT will document)
  44. Forms of Document
    o   Electronic (computing) charting

    o   SOAP notes (most common format)

    o   Narrative notes

    o   Flowsheets, checklist (see Chap. 4)

    o   Insurance / Medicare forms.....done by PT

    o   Reports / Letters to MD........done by PT (mostly in Outpatient)

    o   Incident Reports....done by PT/PTA

    • o   1 unit = 15mins  *******  21
    • units in an 8hr day
  45. S(ubjective)
    o   What the patient tells you; nothing else: examples are…

    § Pt.says… Pt. states… Reports… Pt. c/o…

    § “My back is killing me today…”

    § Includes statements from family
  46. O(bjective)
    o   Rx content are ALL FACTUAL!!!

    § What you did = instruction, training, hands-on work, modalities, provided info, educated patient, etc..

    § What the patient did = demonstrated, performed, ambulated, did exercises, etc..

    § Measurements = ROM, strength, vital signs, etc..

    § Observations = swelling, limping, color changes, etc..

    § Communication with colleagues, family, etc..

    o   ****************after S & O then you’re done with the patient***************
  47. A(ssessment)
    o   Interpretation of data (from ‘S’ and ‘O’)

    § Pt’s response to Rx

    §  Progress towards goals

    *******If you have to think before you write it down, it’s probably an assessment*******

    o   Answer the following questions…

    § How’s it going? Is PT Rx effective?

    § In what way is pt progressing?

    § What still limits the patient?

    §  Draw comparisons to prior Rx’s treatments

    § *****Must be based on ‘S’ and ‘O’ data (and prior documentation)

    o   Key words and phrases…

    • § Û or Ü
    • § Improved

    § Progress limited by..

    § Poor, Fair, Good

    § Consistent/Inconsistent with…

    § Progress towards goals of…

    § Does best with…

    o   ‘A’ should not include…

    § Personal judgements or character descriptions

    • ·patient is angry…
    • ·patient is lazy today…
    • ·patient is manipulative…
    • ·patient is unpleasant to work with…)

    § Medical Connections

    ·Patient is tired due to medications *****it not our scope of practice*****

    ·Not motivated because of depression…
  48. P(lan)
    • o   What to do next with Rx (not the same as
    • the “Rx plan” found in the PT evaluation!)

    • o   Common phrases are…
    • § Continue with…

    • § Consult with PT re:…
    • § Add…

    § Weekly summary due…

    § Call MD

    § Arrange family training

    § Initiate

    § Increase

    § Instruct in

    § D/C  (discontinue for PTA’s because we can’t discharge)
  49. 3 Common Measurements
    o   ROM (Range of Motion)- Goniometry – measure of joint position = use of goniometer (in degrees)

    o   Girth (Circumference) – to measure swelling or muscle mass = inches or centimeters

    o   MMT – Manual technique for estimating the strength of muscle or muscle group
  50. Documentation – need to have or state… *****in objective part of notes******
    o   Motion, joints, R/L/B, AROM/AAROM/PROM, position of patient

    • o   Example: Shoulder ROM = 90­o
    • ….--> it doesn’t tell which side, the motion, position of pt., active or passive
  51. Grades of Muscle Strength
    • o   5 --> N = muscle (or group) can take a “normal” amount of
    • resistence (maximal)

    o   4 --> G = muscle can take ‘some’ resistence (moderate)

    o   3 --> F = muscle can move body part against gravity

    o   2 --> P = muscle can move body part with gravity eliminated   ****usually AAROM****

    o   1 --> trace = muscle can contract but not move the body part   *****usually PROM*****

    o   0 --> absent = zero palpable/visible contraction

    • o   + and - : refers to ‘throughout the
    • range’

    o   ++’s and –‘s
  52. What are Watt's Five Factors to Determine Task Delegation
    • Stability
    • Observability
    • Ambiguity
    • Predictability
    • Criticality
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PTA 101 Midterm
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