PT Fun Exam 1 Study Help PDF

A diagram of a patient model Description automatically generated Learning Objectives weeks 1-8 Week 1: 1. List the steps involved in the Patient Client Management model from initial examination to outcomes. a. Examination b. Evaluation- determines if continuing care or going to r...

A diagram of a patient model Description automatically generated Learning Objectives weeks 1-8 Week 1: 1. List the steps involved in the Patient Client Management model from initial examination to outcomes. a. Examination b. Evaluation- determines if continuing care or going to refer out c. Prognosis/diagnosis d. Intervention e. Outcome 2. Explain the role of the patient client management model in guiding decision making in physical therapy. a. Develops a POC/management plan b. Retains accountability for the POC c. Defines boundaries within which others assisting with service delivery operate d. Always has the option to perform all elements or to direct and supervise PTA, PT techs and others e. Shares info about the management plan with the individual providers as indicated 3. List the four components of the SOAP Note framework. a. Subjective, objective, assessment and plan 4. Explain the purpose and significance of the SOAP Note framework in physical therapy documentation. a. Communication tool among healthcare providers b. Continuity of care and treatment planning c. Legal and ethical considerations 5. Outline the specific information that should be included in each section of a SOAP note. a. Subjective i. History ii. Chief complaint iii. Subjective symptoms iv. Statements made by the patient, caregiver, other healthcare providers or from medical records b. Objective i. Observations ii. Tests and measures iii. Clinical findings iv. Levels of assistance v. Interventions performed and patient response c. Assessment i. Clinical reasoning by analyzing subjective and objective data ii. Formulating opinion based on diagnosis, prognosis, treatment rationale, and clinical impressions iii. Justifying decisions and value to the why and the ICF model d. Plan i. POC based on prognosis, interventions, goals, therapy duration/frequency and coordination ii. Purposes for future actions and follow up visits and their aim and intention to be there, the therapists recall and communication between PT/PTA iii. Demonstrates skill and clinical decision making 6. Match the steps of the Patient Client Management model with the corresponding sections of a SOAP note. a. Examination i. Subjective and objective portions of the note ii. Subjective involves the hx, condition, CC, MOI, Review of systems, pt goals iii. Objective involves the systems review and tests and measures from their aerobic capacity to their work life b. Evaluation, diagnosis, and prognosis i. Assessment portion of note ii. Involving the diagnosis and prognosis c. Prognosis i. Plan section of note in POC ii. Involving the interventions, expected outcomes and anticipated goals 7. Identify the components that comprise the subjective portion of a SOAP note during an initial physical therapy visit. a. Subjective: pt statements, caregiver statements, info from other health care providers and from medical records i. Demographics, current condition (CC, symptom behavior and history, level of function), medical hx and review of systems, social hx, and pt goals b. Objective: data you measure (systems review and tests and measures), observations (functional activities and gait analysis) i. Systems review: cardiopulmonary, integumentary, MSK, neuromuscular, and other communication, affect, cognition, and learning ii. Systematic process and is a quick screening exam to help us determine if PT is needed and drives tests and measure selection (Ex; balance, gait, muscle performance, posture, ROM, sensory integrity) c. Assessment: interpret and integrate exam findings, formulate a PT diagnosis, develop a prognosis i. Systematic approach 1. Intro to client, medical diagnosis, interpretive problem list (impairments, limitations and restrictions, contextual factors), PT diagnosis, prognostic statement d. Plan i. Client status (physical, cognitive and emotional) ii. Expected progression iii. Coordination (PT staff, health care providers, family/caregivers) iv. Discharge status/location v. Goals vi. Frequency and duration vii. Plans for intervention and anticipated discharge plans 8. Recognize the process of collecting and documenting patient information in the subjective exam. 9. Compose a clear and structured subjective section of a SOAP note by integrating information gathered from a patient scenario. 10. Identify the components that comprise the objective portion of a SOAP note during an initial physical therapy visit. 11. Recognize the process of collecting and documenting patient information in the objective exam. 12. Compile in Categorize objective data from a patient scenario into a systemic and coherent objective section of a SOAP note. 13. Identify the components that comprise the assessment portion of a SOAP note during an initial physical therapy visit. 14. Recognize the process of transforming patient information from the examination into a coherent assessment and prognostic statement. 15. Synthesize examination findings for my patient scenario to construct a well-organized assessment section of a SOAP note. 16. Identify the components included in the plan portion of a SOAP note during an initial physical therapy visit. 17. Compose a clear and structured plan section of a SOAP note by integrating information gathered from a patient scenario. 18. Recall the principles of setting SMART goals within an ABCDEF format. a. Specific- who, what, where why i. Impairment goals, activity goals, and participation goals b. Measurable- how much and how many i. Concrete vs abstract ii. Validated and objective measurements c. Achievable- how can I and how realistic is it i. Achievement vs process ii. Achievable vs aspirational d. Relevant- does it have meaning i. Collaborative with pt and family ii. Pt centered e. Timely- by when i. Predictive (reasonable and can be improved with practice) ii. Short term and long term goals 19. Describe the purpose and importance of patient centered goals and how they influence the treatment plan. a. Help PT plan interventions to meet the needs of the pt b. Set objective measures, ensure progress with treatment, and monitor effectiveness of interventions c. Assist with justifying the need for skilled intervention to 3^rd^ party payers d. Communicate purpose and expected outcomes of therapy to other health care providers 20. Develop SMART ABCDEF formatted patient centered goals aligned with assessment findings for a case study. a. Actor i. Who is going to accomplish goal b. Behavior i. What action it is that will be accomplished c. Condition i. Circumstances or context in which behavior is carried out 1. Environment, position, using assistive device, could have many different conditions d. Degree i. Quantified objective measure of the behavior 1. Distance, time, ranges, reps, pain levels, assistance level e. Expected time frame i. Anticipated goal being met 1. Specific dates, weeks, visits f. Function i. Impairment based goals only 1. Ties impairment outcome to a functional activity   1. Identify the essential components of each section in a treatment visit SOAP Note. a. Subjective i. Current status 1. Symptom status 2. Functional improvements (progress toward goals and remaining limitations) ii. Relevant events 1. Response post treatment and between sessions, HEP adherence, new injury or event, medical visits, additional tests/work ups b. Objective i. Observations/tests and measures: updated ii. Interventions performed 1. Clarity and accuracy 2. All needed parameters on sets, reps, machine setting, pt position and equipment used 3. Client education is also considered an intervention iii. Responses to treatment 1. Data only- not your opinion of it 2. Current session only 3. May include pt reported response, observations with interventions, changes in measurements before and after intervention 2. Explain the methods for collecting and recording patient information in each section of a treatment visit SOAP Note. 3. Describe the elements required to create defensible documentation that reflects skilled care in physical therapy. a. Types of information i. Overall progression or lack thereof ii. Assessment of other relevant exam data iii. Assessment of treatment response iv. Justification for PT or discharge v. Follow up plan vi. Adjustments in treatments vii. Plans for future measurement 4. Compile and structure follow up information from a patient scenario into an organized SOAP note format. 5. Identify the essential components of each section in a treatment visit SOAP Note. 6. Explain the methods for collecting and recording patient information in each section of a treatment visit SOAP Note. 7. Describe the elements required to create defensible documentation that reflects skilled care in physical therapy. 8. Compile and structure follow up information from a patient scenario into an organized SOAP note format. Week 2: 1. Identify the key components of effective communication and soft skills required for conducting an initial patient interview. 2. Describe the importance of empathy, active listening in nonverbal communication, and building rapport with patients. 3. Conduct a patient interview using the structured steps demonstrating effective communication skills such as open-ended questioning, active listening and empathy. 4. Identify the components of the ECHOWS format for patient interviews. a. Establish rapport i. Introduction ii. Initial observations (gait, balance, transfers, pt postures, communications) iii. Orient to flow of visit b. Chief concern i. Open ended questions but demonstrate understanding ii. Allow pt to speak uninterrupted iii. System behavior 1. Location and description 2. Intensity (worst, best and current) 3. Aggravating factors 4. Easing factors 5. Frequency/duration 6. 24-hr symptom behavior 7. Symptom history a. MOI b. Timing and pattern of symptoms c. Prior episodes d. Previous exam/interventions 8. Level of function c. Health history i. Medical hx 1. Conditions/illnesses 2. Related previous injuries 3. Surgical hx ii. Medications and allergies 1. Medication dose, prescription 2. Level of allergy and treatment iii. Abuse and family hx 1. Any previous or family hx of sex abuse, family violence, emotional or physical abuse 2. Pertinent family medical hx a. Diabetes b. CAD c. Hypertension d. CA iv. Review of systems 1. Subjective screen of body systems a. Red flags/yellow flags b. Systemic/neuromuscular source c. Health related risk factors d. Refer, treat and refer, or treat v. Obtain psychosocial perspective 1. Environmental factors a. Living environment, occupation, community participation 2. Health habits a. Substance use, exercise 3. Personal actors a. Support network, individual considerations (family, culture, socioeconomic, ethnicity, race, education level, personal circumstances) 4. Patient perception a. Chief concern b. Treatment 5. Patient goals and expectations a. Overall goals and PT encounter goals b. Patient, family or caregiver input c. Redirect/redefine if needed d. Wrap-up i. Closing questions ii. Concerns iii. Transition phase 1. Provide next clear steps 2. Step out of room a. Organize thoughts i. Hypotheses refinement ii. Determine irritability level iii. Plan objective exam 3. If immediate referral (STOP examination process) 4. If delayed referral (continue exam process) e. Summary of performance 5. Recall the types of questions that should be asked at each step of the patient interview. 6. Summarize the types of information that should be gathered from a patient interview. 7. Conduct a patient interview using the structured steps demonstrating effective communication skills such as open-ended questioning, active listening and empathy. 8. Explain the significance of red and yellow flag symptoms in the context of patient screening. a. Red flags must stop treatment and are requiring immediate attention b. Yellow flags need to be cautious and are warning symptoms needing more screening 9. List of body systems and describe general signs and symptoms that are considered red flags within each system. 10. List different pane descriptors and associate them with potentially underlining structures. a. Types of pain i. Cramping, dull, aching- muscle related ii. Sharp, shooting-nerve root related iii. Sharp, bright, lightning like-nerve related iv. Burning, pressure like, stinging, aching- sympathetic nerve related v. Deep, nagging, dull- bone related vi. Sharp, severe, intolerable- fracture related vii. Throbbing, diffuse- vasculature related 11. Describe different signs and symptoms associated with musculoskeletal pain and those associated with systemic pain. a. Systemic: i. Disturbs sleep ii. Deep achy or throbbing iii. Reduced by pressure iv. Constant or waves of pain and or spasm v. Not aggravated by mechanical stress vi. Associated symptoms/red flag findings b. Musculoskeletal: i. Generally, lessens at night ii. Sharp or superficial ache iii. Usually decreases with cessation of activity iv. Usually intermittent v. Aggravated by mechanical stress vi. Absent   Week 3 1. Recall and list the primary components of a comprehensive systems review in physical therapy. a. Cardiopulmonary/pulmonary b. Integumentary c. Musculoskeletal d. Neuromuscular 2. Describe the purpose and importance of conducting a systems review in the physical therapy assessment process. a. Brief or limited hands-on examination of the anatomical and physiological status of these systems b. Communication ability, affect, cognition, language, and learning style of the individual 3. Perform a systems review of the cardiopulmonary system. a. HR, RR, O2, BP 4. Classify vital signs as within or outside of normal parameters. a. HR i. Norm: 60-100 bpm ii. Bradycardia: less than 60 bpm iii. Tachycardia: more than 100 bpm b. BP i. Norm: \>120/80 mmHg c. RR i. 12-20 bpm d. O2 i. 96-100% ii. Hypoxemia levels below 90% iii. Hypoxia diminished supply of O2 available to body tissues iv. Anoxia complete lack of O2 v. Can be taken: finger (should be taken on middle finger due to receiving pulse from radial and ulnar arteries), toe, earlobe (most accurate depending on condition), and forehead (most accurate depending on condition) e. Temp i. Norm: 96.8-100.4 ii. 98.6 typical 5. Demonstrate the ability to accurately take vital signs. Week 4 1. Identify the primary components of the neuromuscular system screen as a part of the systems review process. a. Assess function of CNS and PNS b. Guide for a more in-depth test and measures c. General coordinated movements i. Heel walk, toe walk, deep squat ii. Observing- gait, balance, sitting, standing, transfers and transitions d. Clinical decision making i. Gait- Functional gait assessment ii. Balance- Berg balance scale iii. Locomotion mobility- TUG test iv. Muscle performance- MMT e. Sensation screening i. C4-T1 and L2-S2 f. Reflex testing i. DTR 1. C5-C7 (biceps, brachioradialis and triceps) and L4 and S1(patella and achilles) ii. Pathological reflexes 1. Clonus 2. Babinski g. Gross AROM h. Gross strength 2. They explained the normal and abnormal findings that might be identified during the neuromuscular Systems Review. 3. Demonstrate a neuromuscular systems review as part of a mock physical therapy examination. 4. Identify and describe the key features to be assessed in the integumentary system as part of this systems review. a. Skin coloration b. Palpation of texture, firmness, elasticity and temperature 5. Describe the four components of being alert and oriented. a. Alert: i. Communication ii. Pt demeanor iii. Affect/mood b. Oriented: i. Person ii. Place iii. Time iv. Situation 6. Identify the principles of communication, cognition, and orientation within the systems review process. a. Communication i. Introduction is the start ii. Develops throughout the interview iii. Name and DOB show orientation and cognition of patient b. Cognition i. Mental action or process of acquiring knowledge and understanding through thought, experience, and the senses 1. Perception, memory, learning, and decision making c. Orientation i. Know who they are, where they are, what time and why they are where they are ii. Person, place, time and situation Week 5 1. Demonstrate comprehensive knowledge and understanding of infection control principles and practices in a healthcare setting. a. Practice minimizing contamination to prevent or control the spread of infection b. Maintain a clean environment with hand hygiene, disinfecting surfaces and controlling what touches what c. HAI (healthcare associated infection) refers to infections acquired in any healthcare setting d. Nonsocomial infections are infections acquired in a hospital 2. Implement infection control measures to ensure the safety and well-being of patients, colleagues and themselves during clinical practice. 3. Describe universal isolation precautions. a. Hand hygiene i. Soap and water ii. Hand sanitizer b. PPE i. Gloves ii. Gown c. Respiratory hygiene i. Proper cough etiquette d. Isolation precautions i. Standard 1. Clean hands 2. Clean equipment 3. Practice cough etiquette 4. PPE when in contact with body fluids ii. Contact (physical contact) 1. Clean hands 2. Gown 3. Gloves iii. Droplet (pneumonia, bacterial meningitis, viral influenza, mumps, rubella) 1. Clean hands 2. Mask 3. Face shield OR goggles iv. Airborne (measles, chickenpox, varicella-zoster virus, rubeola) 1. Keep door shut 2. N-95 respirator mask v. Novel respiratory precautions (SARS-CoV-2 or COVID-19) 1. Clean hands 2. Gown 3. Gloves 4. N-95 mask OR PAPR 4. Explain and perform effective infection control. 5. List in Demonstrate use of personal protective equipment. 6. Classify lab values as within or outside normal parameters a. WBC i. Norm: 5,000-10,000 ii. Abnormal: \30,000 b. RBC i. Norm: Male- 4.7-6.1 Female- 4.2-5.4 c. Hemoglobin i. Norm: Male- 14-18 Female: 12-16 ii. Abnormal: \20 d. Hematocrit i. Norm: Male- 42-52% Female- 37-47% ii. Abnormal: \60% e. Platelets i. Norm: 150,000-400,000 ii. Abnormal: \1 million f. Sodium i. Norm: 136-145 ii. Abnormal: \160 g. Potassium i. Norm: 3.5-5.0 ii. Abnormal: \6.5 h. Calcium i. Norm: 9-10.5 ii. Abnormal: \13 i. Glucose i. Norm: 74-106 ii. Abnormal: \400 j. Partial Thromboplastin Time i. Norm: 30-40s ii. Abnormal: \>70s k. International normalized ratio i. Norm: 0.8-1.1 ii. Abnormal: \>5.5 l. Prothrombin time i. Norm: 11.0-12.5s ii. Abnormal: 20s m. D-dimer i. Reference value: \75%) iii. Requires physical assistance (\