Language of PT

Question 1

What is the S in SBAR communication

Answer 1

S = situation
- A concise statement of the problem
- Identify yourself and where you are calling from
- Identify your patient and DOB and the reason for the call

Question 2

What is B in SBAR communication

Answer 2

• B = background
• Pertinent and brief information related to the situation
• Provide the relevant background, - PMH, supporting data; basics first, more depth as needed

Question 3

What is A in SBAR communication

Answer 3

• A = assessment
• Analysis and considerations of options
• What is your clinical assessment? - Do you have one?

Question 4

What is R in SBAR communication

Answer 4

• R = recommendations
  request/recommend action
• What is your suggestion/request? - Have relevant information available

Question 5

What are the elements of the first patient encounter and describe them

Answer 5

• Examination: obtained via subjective interview and hands on tests and measures
• Evaluation, referral/consult, diagnosis, prognosis: this is where the analysis of S and O are used to figure out what is going on
• Intervention: based on your findings, determine what you want to do - Plan (most often perform interventions on the first visit)
• Outcomes: reassess next visit/ongoing

Question 6

What is the first step in a patients first visit?

Answer 6

• interview/obtain history: types of data that may be generated from a patient or client history
• Can be obtained verbally from a patient or a HIPPA approved advocate, from an intake form, a chart or from another health care-professional
• Review of systems: getting information on each system/history

Question 7

Step 2: review of systems for first patient visit

Answer 7

• Simple screen of systems that we should be aware of in every patient
• Cardiopulmonary: the assessment of heart rate, RR, BP and edema
• Integumentary system: the assessment of pliability (texture), presence of scar formation, skin color, skin integrity etc
• Musculoskeletal: the assessment of gross symmetry, gross ROM, gross strength, heigh, and weight
• Neuromuscular: general assessment of gross coordination movement (eg, balance, gait, locomotion, transfers, transitions) and motor function (motor control and motor learning)
• Communication ability, affect, cognition, language and learning style: the assessment of the ability to make needs known, consciousness, orientation, expected emotional/behavioral responses, and learning preferences

Question 8

Step 3 of patient first visit:

Answer 8

• test and measure
• Cannot perform all of these what do we need for this patient based on what we know

Question 9

Step 4 of a patient’s first visit - Bridge to POC

Answer 9

• Interpret the individual’s response to tests and measures
• Integrate the test and measure data with other information collected during history
• Determine a diagnosis or diagnoses amenable to physical therapist management:
• Related to the impairment and functional limitation
• Determine a prognosis and include goals for physical therapy
• Develop interventions and POC