Clinical Kin Notes PDF

Define a patient’s health record: A patient’s health record is detailed written story of their health history and care journey while working with a kinesiologist; What does a patient’s health record provide: Health history Health goals Details of each encounter Outcomes Prognosis; Why is a p...

Define a patient’s health record: A patient’s health record is detailed written story of their health history and care journey while working with a kinesiologist; What does a patient’s health record provide: Health history Health goals Details of each encounter Outcomes Prognosis; Why is a patient’s health record important: Act as a communication tool for others Allow you to track a patient’s progress to see what you need to adjust Determine future care needs Are a memory recall about patients because you see many patients and it keeps you in track; What are the objectives of record keeping: To facilitate the safe and quality care, ensuring what happened and knowledge history To ensure patients have access to up-to-date, accurate information about their health To ensure continuity of care from other treating health professionals To ensure accountability to patients/clients, payors, the College, the profession and other healthcare providers To demonstrate judgement, reasoning and adherence to practice standards of the profession To meet any other requirements mandated by their organizations or where required by law; List the principles of recording keeping: Identifiable Legible and understandable (proper spelling and grammar) Comprehensive (easy to understand by anyone) Accurate the timely (generally within 2hrs, but depends on what the employers wants) Accessible and retrievable (self informed, have to figure it out yourself, and also follow the guidelines and policies of employers) Secure and confidential; How does a kinesiologist demonstrate record keeping: Every part of the record has a unique identifier (hospital number or patient's date of birth) Records are sequential (for example, in yearly order) Every entry is dated and signed Any change made is indicated, while keeping the original (it is important to note that you can’t destroy anything that was originally there) Records are legible Information is entered within a reasonable time period (ASAP or within 24 hours) Appropriate and respectful language is used (anyone in the circle of care can see) An audit trial exists (processes in place by the organization); What should you record: Patient demographic information (patients date of birth, address) Name(s) of primary care physician(s) and any relevant referring health professionals Reason for referral Date, purpose, and mode of contact Patient’s chief complaint(s) or concern(s) and supporting data Relevant past health, family, and social history Every written report and imaging record and reported received by the number that was performed by other health professionals Every cancellation of an appointment and the reason they cancelled Information about each examination, assessment, test, impression, treatment performed, who performed the treatment, any consultation and correspondence with circle care, any informed consent, any recommendations give, every referral to another health professional, any controlled act performed, a procedure that was commenced but not completed or refused and why, real, perceived or potential conflicts of interest, any abbreviations that may be used, and the discharge of the patient; When should an RKin decide to record (document) something when working with patients/clients: After consent is obtained, including what was discussed When taking a health history After an assessment, the results and your interpretations After a treatment, and patient response Upon referral to another health profession Every cancellation; How long must Rkins retain patient/client records: At least 10 years for patients who are 18+ At least 10 years following that date at which a patient would have become 18 years old for patients who are under 18 years old at the time of last contact; What do you do once enough time has elapsed? How to destruct records: It must be done securely and using a method that prevents records from being recovered, reconstructed, or identified For paper copies, place in confidential waste bucket For digital copy, destroy the server; SJHC ‘Clinical Documentation’ Standard Highlights: SJHC policy is based on the DAP Notes methodology (Data, Assessment, Plan). It is like SOAP notes. St. Joseph’s follows Documentation by Assessment Documentation must be complete, accurate, legible (be free of spelling and grammar errors, blue or black ink if written) and timely Must be done by a health care professional, who delivered care, in a timely manner, and include signature, date, and designation Must uniquely identify the patient and not contain value judgements To correct an entry use this format, cross out the statement you are correcting and write “mistaken entry”, explain why, and sign it. Adhere to approved abbreviation list; What is the ACSM 5-step approach: Step 1, screening Step 2, medical history Step 3, fitness assessment Step 4, special considerations Step 5, care plan; Describe the exercise related complications, musculoskeletal injuries: It is the most common exercise related complication Most common within the knees, ankle and foot The risk of MSK is inversely related to physical fitness; Describe the exercise related complications, cardiovascular events: Much less common than MSK injuries but can lead to long-term morbidity and higher risk of mortality CV events are often related to sudden cardiac death and acute myocardial infarction (MI), also known as heart attack, the risk is 3.5 times greater. The chance is low in healthy population participating in moderate exercise. The risk is greater when people are re-participating in vigorous exercise; Understand the graph for exercise related cardiac events: People who are sedentary have a 50% higher chance in MI The more vigorous the activity is, the lower the risk; Describe the mechanism of cardiovascular events: The plaque will rupture and block the passage of blood When someone doesn’t regularly exercise and isn’t physically active plays sports once a week, there is a chance that they will get a heart attack; What is the risk of exercise related cardiovascular events: The risk is extremely low but it is not 0 Use ACSM pre-participation screening; Compare and contrast the new vs old ACSM pre-participation screening algorithm: Old algorithm was based on CVD risk factors, presence/signs of CV, metabolic, or pulmonary disease, and planned PA intensity. It recommends medical examination by a physician. Created barriers to PA and exercise participation. The old algorithm sent 80% of older participants to screening. It was not an effective use of health care professionals. The new algorithm is based on current PA levels, removed pulmonary disease, the signs and symptoms that overlap with cardiovascular disease. It recommends medical clearance instead of examination, it has fewer conservative guidelines, allows physicians to determine what follow ups to use and removes barriers to participation; What is the purpose of the ACSM pre-participation screening algorithm and what is it based on: The purpose is to identify an individual’s risk of exercise related CV event and determine if medical clearance is needed, benefit from medically supervised exercise, and exclusion from exercise until stable Based on current PA levels, presence/signs of CV, metabolic or renal disease, planned PA intensity; Describe step 1 of the ACSM pre-participation screening algorithm: Step 1, are they regularly active? Defined as, performing planned, structured PA of at least moderate intensity for at least 30 mins on 3 or more days per week during the past 3 months (30, 3, 3) To know which stage, use the rate of perceived exertion (RPE) scale. 6 is resting, 20 is the hardest, moderate to vigorous is between 12 to 15 and vigorous is 16-20. ; Describe step 2 of the ACSM pre-participation screening algorithm: Step 2, disease, or signs/symptoms of disease? The ACSM doesn’t consider hypertension (high blood pressure) as a sign or symptom but it is a risk factor for cardiovascular disease Metabolic, type 1 or 2 diabetes (fatigue, extreme thirst, frequent urination, unintentional weight loss) Renal disease, chronic kidney disease or conditions (renal, poor appetite, swelling in the lower body) Angina, any chest discomfort or tightness, shortness of breath, feeling light headed, breaking out in cold sweats, sick to the stomach; Describe step 3 of the ACSM pre-participation screening algorithm: Step 3, planned exercise intensity. Light intensity exercise, an intensity that causes slight increases in HR and breathing, will be able to keep up with conversation. 30-39% heart rate reserve, 2 to