Questions and Answers
What must the physician order read for physical therapy to be done by a physical therapist?
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?
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What specialists may be consulted to address specific medical issues?
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What are surgical notes important for?
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What does the approach of the surgery refer to?
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Precautions include ______.
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What does code status indicate?
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What types of imaging reports and diagnostic tests might be considered?
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Lab values and vital signs should be obtained, including ______.
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What does AIDET stand for?
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What should be the goal of questioning during an interview?
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The environment for effective interviewing should include distractions.
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What should be done during the opening of the interview?
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What should summarizing during an interview accomplish?
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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.
