Physical Therapy Chart Review Flashcards

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Questions and Answers

What must the physician order read for physical therapy to be done by a physical therapist?

PT (correct)

PTT

Who can complete the MD history and physical?

Nurse practitioner or PA

Information that should be obtained in the history includes the patient's ______.

diagnosis, reason for admission

What should documentation do?

Tell a story of the patient's case Signup and view all the answers

What specialists may be consulted to address specific medical issues?

Pulmonologist, cardiologist, neurology, neurosurgery, orthopedics, psychiatry Signup and view all the answers

What are surgical notes important for?

Documenting the specific problem and type of surgery Signup and view all the answers

What does the approach of the surgery refer to?

How the surgeon went in (anteriorly or posteriorly) Signup and view all the answers

Precautions include ______.

weight-bearing status, fall precautions, infection control precautions Signup and view all the answers

What does code status indicate?

The actions to take during a cardiac event Signup and view all the answers

What types of imaging reports and diagnostic tests might be considered?

MRI, CT scan, Doppler, EEG, colonoscopy, x-ray Signup and view all the answers

Lab values and vital signs should be obtained, including ______.

baseline vital signs, most recent lab values Signup and view all the answers

What does AIDET stand for?

Acknowledge, Introduce, Duration, Explanation, Thank you Signup and view all the answers

What should be the goal of questioning during an interview?

Purposeful, simple, logical, and open-ended Signup and view all the answers

The environment for effective interviewing should include distractions.

False Signup and view all the answers

What should be done during the opening of the interview?

Introduce yourself, tell the patient your role, listen, observe Signup and view all the answers

What should summarizing during an interview accomplish?

Determine the patient's understanding of their condition Signup and view all the answers

Study Notes

Physician Order

Required for physical therapy consultation; must clearly state "PT" for therapist involvement.
Essential for legal compliance and can vary in specificity.

MD History and Physical

Can also be conducted by nurse practitioners or physician assistants.

Information to Obtain in History and Physical

Gather diagnosis and admission reasons, medical and surgical history.
Assess social living situation, previous therapy history, medications, and current hospital course.
Include physician’s prognosis and assessment in documentation.

Documentation

Should narrate the patient's journey to their current status.

Specialists for Consultation

May include pulmonologists, cardiologists, neurologists, neurosurgeons, orthopedic surgeons, and psychiatrists.

Surgical Notes

Important for understanding patient history; include surgery type and post-surgical protocols.
Track date of surgery and approach used during the procedure.

Approach of Surgery

Refers to the surgical entry point; requires clarification from the physician if unknown.

Precautions

Include weight-bearing status, code status, fall and infection control precautions, as well as DVT and cardiac precautions.
Document range of motion (ROM) limitations and spinal precautions.

Code Status

Three main types:
- No code: patient not resuscitated.
- Partial code: limited interventions per patient's wishes.
- Full code: aggressive resuscitation measures.

Imaging Reports and Diagnostic Tests

Common tests include MRI, CT scans, Doppler, EEGs, colonoscopies, and X-rays.

Lab Values and Vital Signs

Baseline vital signs are essential, along with the latest lab data.
Important to know if the patient is on oxygen and to what extent.

Consults by Other Disciplines

May involve occupational therapists, speech therapists, nutritionists, wound care nurses, and case management/social work.

Patient Interview

Follow AIDET: acknowledge, introduce, duration, explanation, thank you.
Key opening questions include asking about their reason for visit and current feelings.

Communicative Atmosphere

Focus on establishing a positive interpersonal relationship with the patient.

Nature of the Interview

Defined as a purposeful conversation aimed at achieving specific communication goals.
Establishes rapport and encourages the patient's self-understanding.

Optimal Conditions for Interviewing

Conducted in a private, distraction-free environment with appropriate seating and timing.
Maintain a non-intimidating demeanor by sitting at or below the patient's eye level.

Attitudes

Personal biases must be set aside; promote empathy and active listening during interactions.

Basic Principles of Interviewing

Encourage patient dialogue, maintain eye contact, ask relevant questions, and summarize key points for closure.

Opening of the Interview

Introduce yourself and your role clearly while observing the patient's demeanor and anxieties.

AIDET Framework

Key components to improve patient interaction: Acknowledge, Introduce, Duration, Explanation, Thank you.

Questioning Techniques

Questions should be clear, open-ended to avoid yes/no responses, and logically sequenced.

Responding Techniques

Effective responses may involve clarification, reflection, interpretation, facilitation, or silence to enhance understanding.

Clarification

Use phrases like, "I think I understand what you are saying" to confirm understanding.

Reflection

Ask engaging questions like, "Do you think you have gone as far as you can in therapy?"

Interpretation

Share your understanding of the patient's statements to ensure clarity in communication.

Facilitation

Use affirming phrases like, "I see..." to encourage further dialogue from the patient.

Silence

Provides space to observe non-verbal cues and encourage the patient to express themselves.

Summarizing

Essential for concluding the interview; recaps patient's statements, confirms perception of their condition, and discusses next therapy steps or goals.
If the patient can't communicate, engage caregivers to complete documentation.

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Description

This quiz consists of flashcards that cover essential terms and concepts related to physical therapy chart reviews and patient interviews. Specifically, it includes definitions and explanations for critical terms like physician orders and MD history. Perfect for students and professionals seeking to enhance their understanding of physical therapy protocols.