MSK Lab Module 2 Exam Review PDF

**Study Guide for Module 2 Exam** Many of the questions for this exam are application-based. It is not just about knowing the content → also about being able to apply the content. Make sure you take the time to read each question as you come to it. Here are some big topic areas to address and make...

**Study Guide for Module 2 Exam** Many of the questions for this exam are application-based. It is not just about knowing the content → also about being able to apply the content. Make sure you take the time to read each question as you come to it. Here are some big topic areas to address and make sure to review and study: **[Types of reasoning]** **Clinical reasoning-** "the process used by therapists to plan, direct perform, and reflect on care." It's a key component to developing and managing the therapeutic relationship +-----------------------+-----------------------+-----------------------+ | **Type** | **Definition** | **Example** | +-----------------------+-----------------------+-----------------------+ | *Scientific | A cognitive process | -Your client has | | Reasoning* | of | edema, so you start | | | **problem-solving** | every session with a | | *(Research)* | that involves | paraffin bath. | | | critical thinking and | | | | relation to content, | -Your client has | | | procedural, and | autism, so you start | | | epistemic knowledge. | with SI | | | uses diagnosis, | interventions. | | | impairment and | | | | evidence-based | -Your client is | | | approaches to | having panic attacks | | | informed decision | in the clinic, so you | | | making, **searching | automatically call | | | for the evidence** | the psychologist. | +-----------------------+-----------------------+-----------------------+ | *Procedural | A process of | \- A 3 y/o with | | Reasoning* | reasoning informed by | hemi-CP has been | | | **clinical pathways, | added to your | | *(Procedures)* | protocols, or | caseload. You | | | routines** used **to | research P-CIMT & | | | improve** function. | start outlining a | | | stems from the | program for use in | | | scientific knowledge | the home & in the | | | and evidence-based | clinic. | | | practice patterns | | | | that provide | -A 65 y/o who has | | | generalizable | just had a R total | | | approach strategies | hip replacement. You | | | for a client with a | follow the surgeon's | | | specific diagnostic | protocols & grab a | | | presentation. (Often | hip kit & educational | | | considered the | materials on hip | | | approach that novice | precautions. | | | therapists gravitate | | | | toward) | | +-----------------------+-----------------------+-----------------------+ | *Interactive | Recognizes the | \- A 6 y/o is having | | Reasoning* | **client as expert** | trouble sitting in | | | in their own lived | the classroom. You | | *(Collaborating)* | experiences and as | bring the child a sit | | | such produces a | disc to use in their | | | process of | seat in the classroom | | | interactive reasoning | after collaborating | | | to collect critical | with the teacher. | | | information on the | | | | context of their | -A 32 y/o fell off a | | | lives and occupations | ladder & has a SCI. | | | of importance, | You take extra time | | | **here-and-now | with them to discuss | | | solution generation** | other alternatives to | | | | the ladder. | | | | | | | | -A 19 y/o is in the | | | | session complaining | | | | about a professor. | | | | You share a time that | | | | you were frustrated | | | | with a professor in | | | | school. | +-----------------------+-----------------------+-----------------------+ | *Narrative Reasoning* | The primary way of | -You are working on | | | **making sense of | feeding goals with a | | *(Stories/Coaching)* | human experience,** | 3 y/o who is | | | this reasoning | spoon-fed at home due | | | informed by knowledge | to cultural beliefs. | | | gathered through | You work with the | | | listening to, | teacher to have | | | reflecting on, and | understanding of what | | | empathizing with the | this looks like at | | | client to paint the | home. | | | picture for | | | | developing a | -You are working with | | | client-centered | a male who is very | | | intervention plan, | uncomfortable working | | | **seeking to | on dressing because | | | understand** | you are female. His | | | | beliefs are that his | | | | wife is the only | | | | person who should see | | | | him naked in any way. | | | | You take time to | | | | schedule your | | | | sessions around when | | | | his wife can be there | | | | and you coach the | | | | wife on dressing | | | | strategies. | +-----------------------+-----------------------+-----------------------+ | *Conditional | **Multifaceted** and | -A 65 y/o is | | Reasoning* | **multi-perspective** | extremely frustrated | | | reasoning process | with her arthritis. | | *(Future)* | used to understand | She loved to knit | | | clients needs to | scarves for all her | | | address potential | family and does not | | | shifts and identity | think she can do it | | | because of changes in | anymore. You research | | | functional capacity. | options of different | | | Reasoning that | ways/equipment to | | | incorporates | help her continue to | | | flexibility and | knit as her arthritis | | | responding to the | progresses. | | | clients Ever Changing | | | | Upstream as well as | -A mom is devastated | | | Downstream concerns, | by her 8 y/o son's | | | **future-focus** | diagnosis of DMD. He | | | | loves music & she | | | | thinks he is not | | | | going to be able to | | | | participate anymore. | | | | You meet with a music | | | | therapist & develop a | | | | plan that allows the | | | | 8 y/o to continue to | | | | play & gives ideas | | | | for continued | | | | participation even | | | | after his condition | | | | progresses. | +-----------------------+-----------------------+-----------------------+ | *Pragmatic Reasoning* | Decision making that | -Your client lives in | | | works within the | a rural community and | | *(Resources)* | parameters of the | is about to go home | | | clinical and social | after an inpatient | | | restriction of the | stay. The closest | | | context, the clients | support group is 30 | | | and therapist that | miles away. You start | | | includes time, place | researching | | | and availability of | teletherapy options | | | **resources**. Can | to decrease barriers | | | create dilemmas and | of continuing | | | clinical reasoning | therapy. | | | that force | | | | underground practices | -You are working with | | | | a family to get their | | | | 10 y/o a new manual | | | | lightweight | | | | wheelchair. Medicaid | | | | has denied coverage | | | | of the chair. You | | | | start researching | | | | grants & crowdfunding | | | | sources to help cover | | | | the cost burden on | | | | the family. | +-----------------------+-----------------------+-----------------------+ | *Ethical Reasoning* | In the moment or | -A wheelchair client | | | bigger picture | is in the clinic with | | *(Morals)* | knowledge that | you when the | | | creates a conundrum | insurance company | | | and reasoning among | comes in and | | | client-centered care, | advertises | | | social issues and | wheelchairs and | | | administrative or | devices that the | | | structural | client qualifies for, | | | barriers**, within | but you tell them | | | all others** | that your client | | | | doesn't need these | | | | items. | | | | | | | | -A family comes in | | | | and predominantly | | | | speaks Spanish, but | | | | you don't know | | | | Spanish besides a few | | | | words. The OT before | | | | says that it's okay | | | | to just speak to them | | | | in English | +-----------------------+-----------------------+-----------------------+ **[Occupational Selection, Analysis, Gradation]** ============================================================= - **Occupation-as-Ends** - *Activities lead to the goal occupation* - Support the patient\'s life roles and routines - Match skill demand with/without adaptations - Ex- If the goal is to tie shoes, practice lacing on a board or crossing the mideline with a rope - **Occupation-as-Means** - *Occupation is the activity - graded, remediated, skill & goal focused* - Client-centered activities - To remediate specific skill deficits and impairments - Be within the patient's capacity and challenge: *just-right challenge* - Ex- If the goal is to tie shoes, have the pt actually practice tying on a shoe - **Activity Analysis** - Understanding the activity's components and skill requirements - OTs use this skill when analyzing activities to determine: - whether a patient with specific abilities can be expected to perform an activity - how an activity can be adapted to facilitate improved occupational performance - Primary components: - Activity - Patient performance - Environmental supports and barriers influencing activity participation - Steps: - Identify activity/demands, pt capabilities, and context - physical status, cognitive and visual-perceptual skills, emotional status, cultural background, and interests. - Identify aspects to target - ID therapeutic aspects and value as related to desired performance - Calibrate difficulty level to promote performance - **Gradation** - A type of modification (change) of activity demands *to reduce or increase the activities challenge level* - Doing the SAME activity, but making it harder or easier - One or two dimensions at a time, so each change can be assessed - 4 ways to grade: - Body function - Required performance skill - Object size and properties - Sequence and timing - **Adaptation** - The process of modifying an activity of daily living to enable performance, prevent cumulative trauma injury, or accomplish a therapeutic goal. (Not necessarily changing the activity) - Ex: needing more time, changing how it is done - 4 reasons to adapt: - To make an activity therapeutic - To grade amount and type of exercise offered by an activity along therapeutic continuum - Enable person with physical impairments to perform - Prevent cumulative trauma injury - Ways to adapt activities: - Required body functions: - Positioning - Arranging objects - Modify lever arm length - Actions and performance skills - Performance method and physical context - Level of difficulty - Objects and properties - Materials and textures - Tools and utensil handles - Object size and shape - Color contrast between objects - Supplemental tools and utensils - Adding weights, springs, or rubber bands - Sequencing and Timing - Modify steps - Modify time - **Modify vs. Adapt** - Adaption: the *process* of modifying an activity of daily living to enable performance, prevent cumulative trauma injury, or accomplish a therapeutic goal - a change in the structure, function, or form of the activity to promote a better adjustment to the environment in which the patient lives - may involve changing the tool or the technique used to complete a task. - Modify: changes to the environment and changes to the occupation (behavior) **OTPF knowledge of performance skills, performance patterns, client factors, context, and activity demands** +-----------------------------------+-----------------------------------+ | **Type of OTPF Language** | **Overview of the category with | | | examples** | +-----------------------------------+-----------------------------------+ | *Performance skills* | - observable, goal-directed | | | actions and consist of motor | | | skills, process skills, and | | | social interaction skills | | | | | | - **Ex**: motor, process and | | | social interaction skills | +-----------------------------------+-----------------------------------+ | *Performance patterns* | - Acquired habits, routines, | | | roles, and rituals used in | | | the process of engaging | | | consistently in occupations | | | and can support or hinder | | | occupational performance | | | | | | - help establish lifestyles and | | | occupational balance | | | | | | - **Ex**: habits, routines, | | | roles, and rituals | +-----------------------------------+-----------------------------------+ | *Client factors* | - specific capacities, | | | characteristics, or beliefs | | | that reside within the | | | person, group, or population | | | and influence performance in | | | occupations | | | | | | - Client factors are affected | | | by the presence or absence of | | | illness, disease, | | | deprivation, and disability, | | | as well as by life stages and | | | experiences. | | | | | | - These factors can affect | | | performance skills | | | | | | - **ex:** a client may have | | | weakness in the right arm | | | | | | - **Values, beliefs, | | | spirituality, body functions/ | | | structures** | +-----------------------------------+-----------------------------------+ | *Context* | - Defined as the environmental | | | and personal factors specific | | | to each client (person, | | | group, population) that | | | influence engagement and | | | participation in occupations | | | | | | | | | | | | - **Ex:** environmental and | | | personal factors | +-----------------------------------+-----------------------------------+ | *Activity demands* | - what is typically required to | | | carry out the activity | | | regardless of client and | | | context. | | | | | | - **Ex;** objects used and | | | their properties, space | | | demands (physical), social | | | demands | +-----------------------------------+-----------------------------------+ **Adaptive equipment (go back to the table you all completed in lab with the different types of equipment; think about situations where they would all be used)** +-----------------+-----------------+-----------------+-----------------+ | **Name of | **Picture** | **How is it | **Possible | | Device** | | used?** | Occupations** | +-----------------+-----------------+-----------------+-----------------+ | Sock aid | | Helps with | ADLs: Dressing | | | | donning socks. | | +-----------------+-----------------+-----------------+-----------------+ | Lock laces |  | tightness of | (Donning shoes/ | | | | shoelaces | tying shoes) | | | | without having | | | | | to tie. | | +-----------------+-----------------+-----------------+-----------------+ | Elastic | | Helps to don | ADL: dressing | | shoelaces | | shoes without | (Donning shoes/ | | | | having to | tying shoes) | | | | manipulate | | | | | shoelaces for | | | | | tying. | | +-----------------+-----------------+-----------------+-----------------+ | Dycem |  | to surfaces. | Hygiene | | | | | | | | | | Meal | | | | | preparation/ | | | | | cleanup | +-----------------+-----------------+-----------------+-----------------+ | Button hook | | Helps button | Dressing | | | | and unbutton | | | | | clothing items. | | +-----------------+-----------------+-----------------+-----------------+ | Foam grip |  | item for easier | preparation, | | | | manipulation | work, leisure | | | | | | | | | (ex: | | | | | toothbrush, | | | | | hairbrush) | | +-----------------+-----------------+-----------------+-----------------+ | Bedrail | | Helps stabilize | Sleep/ rest | | | | when getting in | | | | | and out of bed | | | | | and prevents | | | | | from falling. | | +-----------------+-----------------+-----------------+-----------------+ | Adjustable bed |  | individual to | | | | | their desired | Mobility | | | | comfort & helps | | | | | with safe | | | | | transfers. | | +-----------------+-----------------+-----------------+-----------------+ | Trapeze bar | | Helps position | Rest/ sleep | | | | & get in and | | | | | out of the bed. | Mobility | +-----------------+-----------------+-----------------+-----------------+ | Long handled |  | hair with | hygiene/ | | | | individuals who | grooming | | | | have limited | | | | | ROM | | +-----------------+-----------------+-----------------+-----------------+ | Dressing stick | | Helps donning | Dressing | | | | and doffing | | | | | clothes & | | | | | getting hangers | | | | | out of the | | | | | closet. | | +-----------------+-----------------+-----------------+-----------------+ | Reacher/ |  | and grab items. | | +-----------------+-----------------+-----------------+-----------------+ | Shoe horn | | Helps don & | Dressing | | | | doff shoes. | | +-----------------+-----------------+-----------------+-----------------+ | Scoop dish |  | scooping food | swallowing | | | | off plate. | | | | | | Feeding | +-----------------+-----------------+-----------------+-----------------+ | Inner lip | | Helps stabilize | Eating & | | suction cup | | plate & scoop | swallowing | | plate | | food. | | | | | | Feeding | +-----------------+-----------------+-----------------+-----------------+ | Nosey cup |  | drinking when | swallowing | | | | not able to | | | | | fully tilt head | Feeding | | | | back. | | +-----------------+-----------------+-----------------+-----------------+ | Swedish cutting | | Helps hold food | Meal | | board | | in place to be | preparation & | | | | able to chop. | cleanup | +-----------------+-----------------+-----------------+-----------------+ | Swivel spoon |  | feeding/tremors | | | | | | Feeding | +-----------------+-----------------+-----------------+-----------------+ | Handi handle | | Aids in | Meal | | | | pouring/holding | preparation | | | | drink | | | | | containers | Eating | +-----------------+-----------------+-----------------+-----------------+ | T-grip utensil |  | | | | | | | Eating | +-----------------+-----------------+-----------------+-----------------+ | Rocker knife | | | Meal | | | | | preparation | +-----------------+-----------------+-----------------+-----------------+ | Easy grip |  | | | | utensils | | | Eating | +-----------------+-----------------+-----------------+-----------------+ | Shower bench | | | Showering | +-----------------+-----------------+-----------------+-----------------+ | 3 in 1 commode |  | | hygiene | +-----------------+-----------------+-----------------+-----------------+ | Long handled | | | Showering | | sponge | | | | +-----------------+-----------------+-----------------+-----------------+ | Long handled |  | | | +-----------------+-----------------+-----------------+-----------------+ | Nail clipper | | | Personal | | mount/ board | | | hygiene | +-----------------+-----------------+-----------------+-----------------+ | Double sided |  | | | | suction base | | | | +-----------------+-----------------+-----------------+-----------------+ **[Principles of Teaching-Learning]** 6 Essential Principles for the teaching-learning process: 1. [Identification of patients\' meaningful occupational goals:] - Patients discuss occupational needs and goals by developing a profile. The profile gathers information about the patient\'s activity and participation needs and is it important first step to determine what kinds of formal and non-standardized assessments the therapist can use during the evaluation process - **\*Example-** During an initial assessment, a therapist asks an elderly client, "What activities are most important to you?" The client shares a desire to resume gardening. This meaningful goal shapes the therapy sessions, with activities centered on rebuilding strength, balance, and fine motor skills specific to gardening tasks. 2. [Selection of teaching-learning modes compatible with patients\' learning capacities: ] - **\*Example-** A therapist working with a client with mild cognitive impairment uses a combination of visual and tactile aids, such as picture cards and hands-on practice, to teach dressing skills. Recognizing the client's visual learning strength, the therapist uses demonstration and visual cues to support learning retention. - **Instructional modes:** Types of media through which teaching occurs and includes visual, auditory, tactile and multimodal. Therapist determines which instructional mode pt learns best - **Reinforcement**: reward or encouragement and response to patient performance and can be referred in a variety of forms including verbal, visual, tactile or physical - **Facilitative prompts:** Words, phrases, sentences and questions that provide guidance when patients encounter difficulties or challenges. Intended to promote awareness of the to modify task performance - **Self-monitoring aids:** Can be used to facilitate the patient\'s awareness of the need to regularly check the status of health and or behavioral changes. Useful for memory problems. - **Guidance**: instruction intended to help patients modify activity performance to promote optimal function and includes modeling, verbal cues and physical assistance - **Motivational cues:** Prompts that the therapist offers to patients as encouragement during challenging tasks and are intended to promote perseverance - **Therapist support:** Two common roles are: (1) supportive-facilitative in which the therapist avoids direct teaching and allows the patient to assume greater active control over the teaching learning context AND (2) directive instructive in which the therapist uses an instructor approach to actively convey specific information designed to be received by the patient 3. [Addressing patient health and reading literacy:] - **\*Example-** For a client with low health literacy, a therapist avoids medical jargon and uses simple language and visual aids (e.g., step-by-step images) to explain a home exercise program. To ensure understanding, the therapist demonstrates each exercise and has the client repeat the steps - This process depends on patient capacities, skills and preferences, expectation of health information and care providers. - Includes health literacy, functional literacy, knowing where to seek information, communication skills, application skills, etc. 4. [Assessing patient\'s readiness for behavioral and lifestyle change:] - **\*Example-** A therapist assesses a client's readiness to quit smoking by asking open-ended questions about their motivations and concerns. Through conversation, the therapist discovers that while the client is interested in quitting, they're hesitant due to stress triggers. The therapist tailors the approach, focusing on stress - Motivation is a critical dimension when influencing patients to comply or complete treatment - Transtheoretical model of change 5. [Structuring the environment to facilitate learning:] - **\*Example-** For a client relearning how to cook after a stroke, the therapist sets up a practice kitchen with clear labeling on cabinets, easy-grip utensils, and adaptive cutting boards. This structured environment is free of distractions, enhancing focus and reducing the client's cognitive load during learning. - Identification of sensory qualities needed to best facilitate occupational performance in specific environments - Use of social and temporal contexts - Modifying and adapting features of the physical environment 6. [Feedback and practice:] - **\*Example-** During a fine motor skills activity, the therapist provides immediate, positive feedback after each successful grasp of an object, using comments like, "Great grip!" Additionally, the therapist guides the client through repeated practice of the task, gradually decreasing assistance as the client's skills improve. - Feedback based on: availability of the learner, sensory modes, and various definitions of practice. - See principles of feedback below **[Stages of Learning]** Cognitive and motor learning strategies + value/meaning that patients give occupations 1. **Acquisition** a. Occurs when patients learn new skills, develop strategies for learning (either consciously or unconsciously), and apply new learning in desired, natural contexts. b. Begins when information is stored in memory c. Initially requires greater attention and intention d. Learning and relearning occur frequently e. *Example***:** Imagine someone learning to play the piano. In the acquisition stage, they start by learning fundamental skills like proper finger positioning, recognizing musical notes, and playing basic scales. They might practice repeatedly and make errors, but with guidance and repetition, they begin to understand the essentials of how to play. 2. **Retention** f. Storage of information for later use in a familiar situations g. Retrieval or skill practice requires processes: i. Monitoring of learning ii. Cumulative learning iii. Strategy development and utilization iv. *Example:* In the retention stage, the learner can play scales and simple songs more smoothly and with fewer mistakes. They no longer need to consciously think about finger positioning or note recognition, as these actions become more automatic. The focus now shifts to practicing regularly to retain these skills, working on fluency, and possibly expanding their repertoire. 3. **Transfer of skills** h. Application of previously learned knowledge to a new task or activity i. *Example:* In the transfer of skills stage, the learner can take their foundational piano skills and apply them to various scenarios, such as: playing different genres, composing music, performing in different settings, learning new instruments 4. **Generalization** j. Refers to the ability to take a newly learned skill and apply it to a variety of real-life situations k. *Example:* In the generalization stage, the learner can use their piano skills in a wide range of scenarios, such as improvisation or teaching others **[Principles of Feedback and Practice (chapter 4 of Dirette & Gutman)]** - Feedback and practice are essential components of teaching and learning in occupational therapy. Feedback provides information needed to correct errors on practice trials - [Feedback Based on Availability to Learner:] - **Intrinsic feedback**: information available to the patient based on his or her own sensory systems - Ex: In sports, a runner might assess their performance by how their body feels during a race---whether they feel strong, fatigued, or in control---providing intrinsic feedback that can influence their pacing and technique. - **Extrinsic feedback**: information that is supplemental to intrinsic feedback - Ex: The therapist might use a visual tool, like a chart or video, to show the client their progress over time, which serves as external feedback to motivate and guide them in their therapy goals. - **Knowledge of results**: a from of extrinsic feedback in which the outcome of the movement serves as feedback - Ex: \"You successfully put your right arm through the sleeve, but you struggled a bit with the left side. Let's focus on that part next time.\" - keep track of how many times the client successfully completes the dressing task versus how many attempts were made, sharing this progress with the client to reinforce their achievements and motivate them to continue improving. - [Feedback Based on Sensory Modes: ] - **Visual feedback:** is information derived from the visual-perceptual senses - **Auditory feedback**: is information derived from the auditory senses - **Haptic feedback:** information derived from a combination of physical assistance and guidance (tactile, proprioceptive, kinesthetic) - **Multimodal feedback:** information derived from a combination of visual, auditory and multimodal feedback - [Various Definitions of Practice:] - ***Massed versus distributed practice*:** refers to the differences in practice time and rest time. In massed practice, pt practice time during trials is greater than rest time. In distributed practice, pt rest time between practice trials is equal or greater than amount of time for entire trial - ***Constant versus variable practice:*** refers to practice in which training conditions are either constant or variable - ***Random versus blocked practice*:** refers to practice in which the order of tasks is constant and ordered (blocked) or occurs in irregular patterns (random) - ***Whole versus part training:*** refers to practice in which the activity is completed fully (whole) or is broken down into smaller steps (part) - ***Mental practice:*** is the performance of a skill using imagination with no action involved **Videos of interventions (remember, this is an overview of chapter 27 of Dirette & Gutman; it would be helpful to review these and have some ideas of general intervention ideas)** **[Chap 27: Restoring Activities of Daily Living]** - **Levels of Independence:** - *Independent*: Clients can perform the activity independently; without modification of technique, assistive devices, or aids; and within a reasonable time frame. - *Modified independence*: Clients either require an assistive device to complete the activity, the activity takes more than a reasonable time, or safety considerations exist. - *Supervision (standby assistance)*: Clients require a therapist to stand by for safety in case of balance loss. Therapists may provide verbal cues for safety. - *Contact guard*: Therapists place one or two hands on the client's body to maintain balance, dynamic stability, or safety; however, they do not assist in task performance. - *Minimal assistance*: Therapists provide 25% of assistance (physical or verbal), and clients are able to perform 75% or more of the activity. - *Moderate assistance*: Therapists provide 50% of assistance (physical or verbal), and clients are able to perform 50% to 74% of the activity. - *Maximal assistance*: Therapists provide 75% of assistance (physical or verbal), and clients are able to perform 25% to 49% of the activity. - *Dependent:* Therapist provides more than 75% of assistance (physical or verbal), and clients are able to perform less than 25% of the activity. - Ex) General Weakness - Showering- use long long-handled sponge - Eating food- weighted utensils, handle for milk carton, use t-grip utensils - Nail trimming/grooming- Adaptive nail clipper that suctions to the table - Dressing- placing arms through holes first then brining overhead - Spinal cord weakness- bedside commode, alarm to prevent bed wetting, side railings - Lower body dressing- reacher, sock aid, shoe horn, dressing stick - Upper body weakness when getting in and out of bed- using bed rails- graded down, no bed rails- graded up **Transfers** - **Definitions** - *Transfer:* moving from one functional surface to another - *Lateral transfer (Popover transfer):* moving from one surface to another in a mostly seated position, using arms to lift from surface; one movement or increments - *Modified Stand Pivot Transfer:* "crouched" stand pivot transfer - *Sliding Board Transfer:* seated, transfer aid to slide on - *Stand or squat pivot transfer:* person moves one surface to another by standing fully or near fully upright, pivot feet back up to the landing surface, then sits (requires pt to safely bear weight through legs) - Patients often classified based on level assistance they require to complete specific activities - minimum assistance is 1 to 25% - moderate assistance is 26 to 50% - maximum assistance is 51 to 75% - dependent is greater than 75% - **Principles** - Equipment set up properly - Feet should be able to pivot without steps, chair positioned about 45 deg from the other transfer surface - Wheels locked and footrests out of the way - Weight shift and body mechanics - Shift weight forward - Ex mechanics: tenodesis grip maintained, hand grip, low back muscles - Preparing for the transfer - Double check setup, ensuring wheels are locked - Position self - Prepare client - Use Momentum - To compensate for weakness - **Safety Precautions** - Check medical Hx - Ensure safe environment - No lines in the way - Gait belt - Check for colostomy bag, feeding tube, etc - Use clear, concise verbal instructions or visually demonstrate prior - **Procedure for Completing a Transfer** - Think back to the practical **[Anatomical Principles of Transfers and Functional Mobility ]** - ***Stability:*** the ability to maintain control over the position or movement of your body - Ex- maintaining a yoga pose or simply sitting upright - Enhance by increasing the BOS and maintaining the LOG in BOS - ***Base of Support (BOS):*** part which comes into contact with the ground surface (e.g., feet, legs of chair or a cane) and the more points of contact and larger distance between them, the better the BOS and stability - Ex- standing with feet shoulder-width apart = greater stability than narrow stance - ***Center of Gravity (COG):*** focal point at which gravity acts (pulls) and around which the weight of an object is evenly distributed, it is dependent on the position you're in - Lowering a person's COG increases stability - ***Line of Gravity (LOG):*** a vertical line extending downward from the COG to the ground representing the downward force of gravity acting on the body - When the LOG falls within the BOS, the body is anatomically stable - ***Position:*** the general static location of an object or individual in space - ***Posture:*** relative position of the segments of the body, trunk, extremities and head that change in response to the demands of activity - More complex and dynamic than position - ***Postural Alignment:*** the collective positions of body segments in realtion to position, ability to achieve or maintain a balanced body position for a given activity, postural alignment and postural control go hand-in-hand - Ideal: symmetry of core and extremities for equal force distribution and balance - If you have a stronger BOS and the core is supported, you have better postural alignment, and therefore more postural control - ***Postural Control**:* the ability to achieve or maintain a balanced body position for a given activity depending on sensory and motor input/output to accommodate tasks demands. - Involves voluntary and involuntary adjustments of the body. - ***Postural Analysis:*** to examine the individual, their environment, the purposeful activity involved - ***Ergonomics*:** the study of human interaction and efficiency within the work environment **[Rules around Documentation & Ethical Principles]** - **Purpose of OT documentation** - Provide chonological, timely, accurate, and complete information about all services provided - Includes observations, assessments, interventions, and patient's repsonses - **Documentation format** - *Narrative format:* sequence of events, descriptive, can be time-consuming - *Template format:* fill in data fields, efficient, doesn't provide full picture - *Acronym format:* highly structured, most common is SOAP notes - Ensure documentation is consistent with the legal definition of OT practice for the state - Legibility, timeliness, completeness, accuracy, and authenticity - **Documentation categories** - *Evaluation phase:* screening, evaluation, and reevaluation - *Intervention phase:* intervention plan, contact and progress notes, transition plan - *Discharge phase:* discontinuation note - **General guiding principles of OT documentation** - Objective and factual - Accurate and consice - Correct grammar and spelling - Avoid jargon and slang - Using only approved abbreviations - Writing legible and clear - Promptly recorded - Date, time, signed in all entries - Medicare needs documentation to reflect medically necessary and skilled services include goals focused to improve impairments or functional limitations. - Never erase or remove entries from the record - **Ethics related to documentation** - If you do something but don\'t document it, the court will determine that it never happened. - Do not copy and paste notes from previous days - Document when giving instructions to a client, and they were able to demonstrate understanding of the instructions- nodding or gesturing is not good enough to demonstrate understanding. - Document telephone conversations and results of those conversations - With errors- draw a single line through them - Don\'t leave lines or sections blank, fill it with a line. - Do not document in advance of service being delivered even if you are sure what is going to be done in the next session. - Medical record - Legal document - Ownership (facility or practice generating patient record is the owner) but all information documented belongs to the patient and health care provider - Privacy and confidentiality- HIPAA - Retention-- state laws determine how long medical records should be retained. - Ethical challenges - Documenting services that were not provided - Using wrong billing codes - Co-signing notes without providing proper supervision - False documentation for reimbursements - COTA - The OTR is responsible for signing off on treatment done by OTR and OTA/COTA **[Writing Measurable, Occupation-Based Goals & Objectives]** - **Occupation-based problem statements:** - \[contributing factors\] **results in/limits** \[the area of occupation affected\] - Contributing factor is usually not their diagnosis, but a symptom of it - Ex- Decreased B UE AROM **limits** independence in upper body dressing. & Inability to recognize fatigue when standing **results in** decreased safety with laundry tasks - [Goals must be:] - Occupation-based (always) - Measurable (allows for specificity) - Observable - Action-oriented - If a dead person can do it, it isn't an action (ex- stay in one place, be still) - Realistic - Achievable within amount of time - [Goals focus on:] functional improvements in occupational performance - Talk about what the client WILL do, not what they can not do - Use action verbs (accesses, creates, keeps, knits, reacher, records, loosens, dons, asks) - Verbs to avoid- commits, feels, loves, infers, realizes, wants, thinks - Except for maintenance goals, most goals need to describe change - **[Types of Goals:]** - Goals *in an intervention plan = **long-term goals (LTGs) or outcomes*****.** These are usually discharge goals. - For each problem identified, you must have at least one LTG - Goals meant for smaller increments while *progressing toward the LTG are called **short-term goals (STGs) or objectives*** - You can have several STGs for each LTG - Goal Writing Components (used within all formats) ------------------------------------------------- - Who - What - Where/ How - Amount of Assistance - When - [COAST method for writing OT goals:] - **C- Client** - Client will... - Focus on the client (use name, initials,"pt", etc.) - **O- Occupation** - Perform which occupation? - Should relate to a problem statement established - The essential focus of the goal statement - May need an action verb (e.g., perform or complete) - **A- Assist Level** - With how much assistance/independence? - Level of independence client is expected to demonstrate - Assist levels based on client's expected level of performance at discharge - **S- Specific Considerations** - Under what conditions? - How, where, with what, with whom client will be performing occupation - Makes the goal measurable - **T- Timeline** - By when? - Timeframe in which the goal is expected to be accomplished/completed - Different settings have different timeline expectations - In rare cases, the "A" or "S" may be omitted, but never both - Always keep the "C" and "O" together - **Examples:** - Varsha will tie her shoe with one verbal cue using the bunny ears method within one month. - Ndomo will prepare a meal for his dog, following the task checklist, independently, within one week - The client will independently send a text using the speech to text function on his smart phone by July 19, 2014 **[SOAP Notes]** **(understand the parts of the note, where things go, what type of statements go where)** - **S = subjective** - Direct quotes or a summary of what they said - Reports from client, caregiver, family - Be concise, coherent, and don't repeat the client's history - May include the patient\'s chief complaint and goal for therapy - Ex: Patient reports pain in right hand has decreased since last therapy session - **O = objective** - Description of what the client is doing - Always starts with **"Client participated in [(\#) min] OT session for [(occupaiton/activity)]"** - If session focuses on intervention, start with "Client pariticpated in [(\#)] min OT session [(in what setting)] for [(intervention)] for [(what occupational gain)"] - Summary of observations - Chronologically - Categorically (e.g., client factors, functional mobiltiy, ROM, etc.) - Summary of the interventions provided + response to treatment (data collected) - Steps - 1- begin with statement about length, setting, and purpose - 2- provide brief overview of client's key deficits - 3- follow with summary of client's performance and skilled interventions - 4- be professional, concise, and specific - Observations, tests, and assessment results should be recorded here. - Ex: Patients continue to attend OT twice a week for pain management and ROM following right carpal tunnel release. Pain decreased from 5 to 1 to 10 scale; AROM wrist flexion of degrees to 20 degrees and wrist extension 0-15 degrees. BADL improved; patient able to hold hair brush to style hair now. - **A = assessment** - Interpret the meaning of the S and O sections *(DON"T introduce new topics)* - Types of statements, the 3 P's: - Problems - Impacts on function - "[(Contributing factor/s)] results in or limits [(area of occupation affected)]" - Progress - Whether the OT treatment is effective - Potential - "[(Observation of improved performance)] indicated [(potential and/or progress)]" - Ex: Patient remains motivated and actively participates in therapy. She demonstrates improvements in AROM of the right wrist; pain is decreased and as a result, the patient is using their right hand more during grooming activities. Patient is progressing towards goals and is compliant with her home exercise program. - Always end the statement with a justification **"Client would/would not benefit from continued OT services for... "** - **P = planning** - 1st sentence is description of OT session with the purpose, 2nd sentence is about the focus of OT service - *Format always:* - OT services are recommended for [(\#)] minutes, [(\#x)/(duration)] to address [(problem)] and [(problem)] for [(area of occupation)]. OT sessions will address [(how to incorporate intervention)] in multiple [(area of occupation)] activities. - Frequency- how often or length of session - Duration- how long OT will continue - Purpose of continued therapy and/or specific interventions - Another practitioner should be able to read the P and continue sessions in your client's treatment - Provision of any home program and referrals to other providers. - Ex- continue therapy twice a week as per MD order; begin gentle resistive activities next session. Home program was reviewed and updated to include grasp strengthening. [Example SOAP note: ] S- Client did not verbally report any symptoms that have been bothering her. O- Client completed a 15 minute OT session demonstrating her ability to dish wash. Client required a mod A during ambulation with a walker because of decreased muscle weakness. Client required CGA when standing at the counter because of decreased muscle weakness. Client required verbal cues for directions on next steps in the activities. Client required mod A to complete washing dishes. A- Client demonstrates a decrease in muscle strength resulting in the inability to wash dishes independently. OT sessions will focus on increasing clients muscle strength to address washing dishes independently. P- Client will continue therapy twice a week for 30 minutes. Home programs will be reviewed to include muscle strengthening exercises to help with washing dishes independently. In future sessions OT will address muscle strengthening for ability to complete ADL such as dish washington independently. **[Descriptive, Evaluative, and Interpretive Statements]** - *Descriptive*- statements that are objective, they describe what you can see, hear, taste, touch, or smell. - Ex: she wore a red dress. He sat down on the edge of the bed and took off his shoe. He ate everything on the right side of his plate, leaving the food on the left side untouched. She looked over her left shoulder and mumbled "get away" six times in the half house she was in the room. She said "please" and "thank you" consistently throughout the session - *Interpretive*- based on observations or data but draw some inference or conclusion about the observation or data - She usually wears a red dress. He had to sit down on the edge of the bed to take off his shoes. He did not appear to notice the food on the left side of his plate. She seemed to be hallucinating about someone standing too close behind her. She had good manners. - *Evaluation-* statements pass judgment on something, it is obvious that the person making the statement feels good or bad about it, satisfied or dissatisfied, angry or accepting - She wore a beautiful red dress. He was too lazy to bend over and take his shoes off. He is careless. She acted like a crazy person. She is a very pleasant person. **Types of goals** - *Restorative goals* - Also known as remediative - Used when you have a client who used to be able to do a task but now cannot, usually caused by an illness or injury - Ex: by discharge the patient will be able to independently feed herself three meals a day - *Habilitative goals* - Goals that teach client a new skills that the client never had, typically because of delayed development (task that has never been done before) - Often with children or adults with developmental disabilities - Ex: Eric will write his name legibly on all his school papers by June 10th - *Maintenance goals* - Keep client at their current level of function despite disease processes - Usually written in a long-term care outpatient setting - Sometimes written when condition is so complex that only is specific person with knowledge can carry out intervention - Concern is that many third-party payers will not pay for them b/c no progress - Ex: Client will maintain Independence in dressing for the next 3 months - *Modification goals* - Also called compensation or adaptation goals - Seek to change the context or activity demands rather than change the skills and abilities of the client - Difficult to write as they sound prescriptive and limiting - Ex: increasing the strength and range of motion in an elderly client, address adapting the environment or tools to complete the task - *Preventative goals* - To assist persons who are at risk for developing occupational performance problems - Person may or may not be completely healthy at the time the goal is written - Could be through repetitive motion injury - Ex: by discharge the client will consistently demonstrate proper body mechanics while lifting - *Health promotion* - Goals that relate to health promotion written for clients who may not have a disability but are more about enrichment or enhancement of occupational performance, can be applied to a person, group or community - Usually no attempt to correct a performance deficit rather the emphasis is on enhancing the context and activities to enable maximum participation - Ex: by the end of this class parents will demonstrate minimal competency in infant massage