Week 2- Documentation Prognosis, Documentation Plan of Care, Communication: SBAR, E-Stim Basics, E-Stem Types/Uses Flashcards
DOCUMENTATION: PROGNOSIS
DOCUMENTATION: PROGNOSIS
What is prognosis?
Predicted optimal level of improvement in function and amount of time needed to reach that level.
The prognosis is established after the _________ is determined and is crucial in the development of the _____.
- diagnosis
- POC (Plan of Care)
What are the 2 main things that must be included in a prognosis?
- ) Predicted level of improvement
2. ) Time needed to reach said level of improvement
A prognosis must also include a discussion of _______ likely to influence prognosis to justify your reasoning for determining the prognosis.
factors
What are 6 things that affect prognostic considerations?
- ) Severity
- ) Complexity
- ) Acuity of Pathology or Pathophysiology
- ) Impairements in Body Function and Structures
- ) Activity Limitations
- ) Participation Restrictions
What are examples of complexity when looking at prognostic considerations?
- comorbities
- pre-existing conditions
- social and emotional status
Factors That Can Influence Prognosis:
- Age
- Motivation/Patient __________
- Prior activity level
- Home support
- Cognitive/mental status
- Comorbidities
- Anatomical changes__________ to dysfunction
- Health status
- Psychosocial and ___________ factors
- Availability to resources
- Acute vs _________ problem
- Concomitant conditions
- Severity of the current condition/level of impairment
- compliance
- secondary
- socioeconomic
- chronic
Do acute or chronic problems have better prognosis?
Acute
What model do we use to help determine prognosis?
ICF model
Prognosis Examples:
1.) “Patient demonstrates significant deficit in quad strength and activation”. What might be a likely conclusion based off this information?
2.) “Patient highly motivated to return to their sport coupled with the fact that the patient was healthy and active prior to injury”. What might be a likely conclusion based off this information?
- ) Likely to conclude that regaining full quad strength/control will exceed normal or expected timeframe.
- ) Likely to determine that the patient will achieve predicted optimal level of function at an accelerated rate.
Where is the prognosis documented in the initial evaluation?
POC (Plan of Care) or Assessment
When documenting prognosis it is important to make an ______ statement (excellent, good, fair, poor) regarding the patient’s capacity to improve to the level you have designated as their predicted optimal level of function.
explicit
- In documenting a prognosis it is important to include the _______ regarding why you are making this judgement as well as a ________ of the factors influencing the prognosis.
- Why is this important?
- details
- discussion
-Justifies the need for skilled physical therapy.
Documentation: Prognosis
- Need to include _____________ potential
- Documented in the ______ or __________
- Typically a ____-word statement
- However, the statement needs to be sustained by your ___________ for coming to this conclusion
- rehabilitation
- POC or Assessment
- one
- clinical reasoning
Is this a good example of a proper prognosis?
“The patient demonstrates excellent prognosis and rehab potential.”
Why or why not?
-No, does not have clinical reasoning as to why they have an excellent prognosis and why they have potential for rehab.
DOCUMENTATION: PLAN OF CARE
DOCUMENTATION: PLAN OF CARE
What is the purpose of the POC (Plan of Care)?
Specifies general interventions to be used and anticipated frequency and duration of physical therapy visits.
What are the 4 components of the POC?
- ) Specific goals
- ) Predicted level of optimal improvement/ anticipated discharge plans
- ) General interventions to be used
- ) Proposed duration and frequency
Our goals should include ______ and _____ term goals. We should apply the ____ model to goal writing. Finally, goals must be ______-centered, objective, measurable, functional and include a time element for achieving the goal.
- short and long-term
- ICF
- patient
It is IMPORTANT to relate goals back to _________.
function
What are the 5 criteria for goals?
- Patient/client centered
- Objective
- Measurable
- Functional
- Time-dependent
Goals should be directly related to impairments, ______ limitations and _______ restrictions.
- activity
- participation
If you did not measure a specific characteristic, can you set a goal for it?
No
What would be a better example of this goal?
“Improve active shoulder flexion ROM by 20 degrees.”
The patient will demonstrate improved active shoulder flexion range of motion by 20 degrees to allow patient to reach overhead shelf in the bathroom in 2 weeks.
When do we start our planning for discharge?
Day 1
Where is the predicted level of optimal improvement documented?
Assessment or POC
It is important to also list additional details regarding discharge plans for your patient including things such as what?
- Recommendations for transitioning to an alternative setting at DC
- Coordination with other team members required for pt education
POC also involves listing specific ___________ to be used.
interventions
Interventions implemented need to be consistent with the ________ and _________ of the patient.
- diagnosis
- prognosis
It is also appropriate to indicate how the intervention is intended to be _________.
delivered
- PT/PTA team
- By a PT other that the evaluating PT
Interventions should be specifically chosen for the patient based on the impairments, ______ limitations, ___________ restrictions and contextual factors identified for your specific patient.
- activity
- participation
Factors Influencing the Selection of Interventions:
- Chronicity/severity of the condition
- Level of current impairment/probability of prolonged impairment of body functions/structures
- _______ limitations
- _________ restrictions
- Living environment
- Multisite or multisystem involvement
- Overall physical function and health status
- Potential destination at conclusion of care
- Preexisting systemic conditions or diseases
- Social supports
- _________ of the condition
- Activity
- Participation
- Stability
Lastly, a POC involves the proposed _________ and __________.
- duration
- frequency
Both duration and frequency may be estimated by taking what into consideration?
- setting you practice in
- capacity of your patient to participate in the POC
- patient transportation needs
- limitations mandated by 3rd party payers
Who is important to include in the decision of duration and frequency of POC?
- patient
- family
Modifications to the POC require a _____________ to be performed.
reevaluation
What 3 things constitute a change in status?
- patient’s function has diminished
- patient’s function has not changed
- patient’s function has improved
What is performed to evaluate progress and to modify or redirect intervention?
Reexamination
What are some reasons to perform a reexamination?
- Unanticipated change in the patient’s status
- Failure to respond to PT intervention as expected
- The need for a new POC and/or time factors based on state practice act or other requirements
What are the 4 components of the reexamination?
- ) Clinical impression or diagnosis
- ) Objective reassessment of tests and measures and outcome tools
- ) Goal status
- ) Evaluation
EFFECTIVE AND SAFE COMMUNICATION: SBAR
EFFECTIVE AND SAFE COMMUNICATION: SBAR
- Hospital medical errors are the _____ leading cause of death in the United States; upward of 700 people die per day due to medical errors.
- Communication failure has been found to be the root cause in nearly __% of these deaths.
- third
- 70%
What are some communication barriers in healthcare?
- lack of structure and standardization for communication
- the existance of cultural differences in authority, gender, and race
- healthcare team members may have different communication styles
What does SBAR stand for?
S- Situation
-What is the immediate problem/situation?
B- Background
-What is the relevant background to the issue/problem?
A- Assessment
-What are your conclusions about the present situation?
R- Recommendation
-What can be done to correct the problem?
SBAR creates a common ________ as well as a format for discussion and partnerships via collaborative communication.
language
_____ provides effective and efficient ways to communicate and also offers a simple way to standardize communication by using 4 common elements.
SBAR
What preparation is needed to communicate with SBAR?
- gather relevant info
- formulate thoughts in a concise manner
- make sure your message is clear
ELECTRICAL STIMULATION: THE BASICS
ELECTRICAL STIMULATION: THE BASICS
Goals and Indications for E-Stim:
- _____ modulation
- Decrease muscle spasm
- Improve ____
- Muscle re-education
- Improve muscle strength/reduce _______
- Wound healing
- Edema reduction
- Stimulate denervated muscle
- Pain
- ROM
- atrophy
What are the contraindications for performing E-stim?
- Anywhere in the body for someone with a pacemaker or other electronic medical device (insulin pump)
- Over carotid artery, thrombosis, eyes, phrenic nerve, pelvis and/or low back in pregnant women
- Transcerebrally
- In presence of active bleeding or infection
- Over superficial metal implants
- Over malignant tumors
- Over pharyngeal or laryngeal muscles
- Motor-level stimulation in conditions that prohibit motion
What are the precautions for performing E-stim?
- Cardiac disease
- Impaired mentation
- Impaired sensation
- In areas of skin irritation or open wounds
- In patient with uncontrolled hypotension or hypertension
- Bleeding disorders
- Like charges _____ while opposite _______.
- Can charges be transferred from one object to another?
- repel, attract
- Yes
- What is polarity?
- What is cathode?
- What is anode?
- polarity= net charge of an object
- cathode= net negativity
- anode= net positivity
