Communication, Documentation, and the ICF Model Flashcards

1
Q

What are the four types of communication?

A

1) Verbal
2) Nonverbal
3) Audiovisual AIDS and Assistive Technology
4) Written

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2
Q

Communication in medical encounters comprises of what two aspects?

A

Verbal and Non-Verbal Aspects

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3
Q

If verbal and non-verbal forms of communication are inconsistent or contradictory, what will override what?

A

The non-verbal messages tend to override the verbal messages

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4
Q

What four things should you consider with verbal communication?

A

1) Consider tone and volume
2) Use lay terms that give direct information
3) Be brief and concise for safety and instructions
4) Assess the patients understanding

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5
Q

What kind of tone is ideal to have?

A
  • Calming
  • Stimulating
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6
Q

What makes up most human communication?

A

Non-verbal communication

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7
Q

What is considered to be more effective: verbal or nonverbal communication?

A

Non-verbal communication

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8
Q

What are examples of non-verbal communication?

A
  • Appearance: dress, grooming, cleanliness
  • Body Movements: abrupt, slow, threatening, caring
  • Body Positions: sitting, standing, walking, kneeling
  • Facial Expressions: smiling, frowning, grimacing
  • Gestures: using hands and arms to guide or direct
  • Pantomime: demonstrating the activity
  • Posture: erect, slouched, rigid
  • Spontaneous response to stress: blushing, perspiring, trembling
  • Touch: therapeutic, caring, directive, guiding
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9
Q

What is active listening?

A

Specific way of hearing what a person says and feels and reflecting that information back to the speaker

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10
Q

What is the goal of active listening?

A

Listen to the whole person and provide them with empathetic understanding

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11
Q

What is the difference between empathy and sympathy?

A
  • Empathy is considered to be compassion and understanding for another person
  • Sympathy is considered to be pity for another person
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12
Q

What is better for patient care: empathy or sympathy?

A

Empathy

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13
Q

According to studies, negative _____ and lack of _____ can worsen outcomes and can even have a small affect on pain.

A

Expectations; Empathy

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14
Q

What are the four reasons we preform active listening?

A

1) Shows patients you care
2) Establishes trust and helps build rapport
3) Lessens chances of erroneous treatment/ decision-making, based on your assumptions
4) Increases chances that you’ll get relevant information

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15
Q

There are lots of ways to active listen, what are the 6 main categories?

A

1) Undivided Attention
2) Body Language
3) Respect
4) Acknowledgement/ Attentiveness
5) Nonjudgemental Attitude
6) Response

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16
Q

What are some barriers to effective communication?

A
  • Physical distance
  • Noise and environmental distractions
  • Receptive Deficits
  • Decreased feedback
  • Different interpretations
  • Use of complicated vs lay language
  • Cultural, gender, or age differences
  • Illegible writing
  • Inefficient multitasking
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17
Q

What is an example of patient first language?

A

“My patient has” or “My patient with”

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18
Q

The ICF model is a _____ _____ which can be used to interpret clinical information in a way that focuses on ability.

A

Conceptual Framework

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19
Q

The ICF model provides what kind of language and framework for the description of health and health-related states?

A

Standard Language

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20
Q

The ICF model is necessary to aide in what?

A

The clinical decision making process

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21
Q

What makes up an ICF model?

A
  • Health Condition (ex: total knee)
  • Body Functions and Structures (ex: ROM, Strength, Pain)
  • Activity (ex: Running, Swimming, Biking)
  • Participation (ex: Triathlete)
  • Environmental Factors (ex: Car, Bike)
  • Personal Factors (ex: Age, Gender)
22
Q

Body Functions are …

A

physiological functions of body systems (including psychological functions)

23
Q

Body Structures are …

A

anatomical prats of the body such as organs, limbs, and their components

24
Q

Impairments are …

A

problems in the body function or structure such as a significant deviation or loss

25
Q

Activity is …

A

the execution of a task or action by an individual

26
Q

Participation is …

A

involvement in a life situation

27
Q

Activity Limitations are …

A

difficulties an individual may have in executing activities

28
Q

Participation Restrictions are …

A

problems an individual may experience in involvement in life situations

29
Q

Environmental Factors make up …

A

the physical, social and. attitudinal environment in which people live and conduct their lives

30
Q

Documentation is a written form of _____.

A

Communication

31
Q

Any entry into a patients permeant health record is protected by _____.

A

HIPAA

32
Q

Clinical documentation of patients is a professional responsibility and a ______ ______.

A

Legal requirement

33
Q

Documentation is critical to ensure what?

A

That individuals receive appropriate, comprehensive, efficient, person centered, and high-quality health care services throughout the episode of care

34
Q

Most hospitals at this time use what kind of health record?

A

Electronic medical records (EMR)

35
Q

What are the 5 reasons we document?

A
  1. You legally have to
  2. Used to reflect best practice in patient care
  3. Necessary for payment and reimbursement
  4. Demonstrates compliance to avoid risk
  5. Serves as a narrative for you and those working with you to follow a plan of care (POC)
36
Q

What does S.O.A.P. stand for?

A
  • Subjective
  • Objective
  • Assessment
  • Plan
37
Q

What is your subjective and what is a part of it?

A
  • The history section
  • Chart review, patient chief complain (CC)
38
Q

What is your objective and what is a part of it?

A
  • The physical exam and laboratory data section
  • Lab findings, examination, physical exam results
39
Q

What is your assessment and what is a part of it?

A
  • Your assessment of the patients problems
  • Treatment diagnosis based on subjective/ objective findings
40
Q

What is your plan and what is a part of it?

A
  • Your plan for the patient based on the problems you’ve identified
  • Planned interventions, frequency of treatment, goals for patient
41
Q

The subjective includes anything the patient, family member, or caregiver tells you in addition to what?

A

What is found in the history and physical (H&P)

42
Q

The subjective includes but is not limited to:

A
  • History of present illness (HPI)
  • Mechanism of injury (MOI)
  • Chief complaint (CC)
  • Information about lifestyle (living environment or situation)
  • Date of injury/ onset date (DOI)
  • Past medical history (PMH)
  • Prior and current levels of function (PLOF and CLOF)
  • Patients goals for PT
43
Q

Where do you document the results of all your testing/ screenings?

A

Objective

44
Q

Where do you document everything you intervened on?

A

Objective

45
Q

The clinical impression (general impression of the patient), also considered to be the subjective plus the objective, goes in what part of your note?

A

Assessment

46
Q

What part of the note would you link the impairment found in the initial examination to the patients activity limitations and participation restrictions?

A

Assessment

47
Q

The assessment provides proof that skilled physical therapy is what?

A

Medically necessary

48
Q

Your plan should include what 5 things?

A
  1. Plan of interventions to address impairments, activity limitations and participation restrictions
  2. Frequency of visits
  3. Expected number of visits
  4. Goals
  5. Discharge recommendations
49
Q

What are the two types of goals?

A
  • Long term goals (LTG)
  • Short term goals (STG)
50
Q

How should goals be written?

A

S.M.A.R.T.
- Specific/ Significant
- Measurable/ Meaningful
- Achievable/ Action-Oriented
- Relevant/ Realistic
- Time-based/ Trackable

51
Q

When someone says a goal needs to be measurable, what does that mean?

A

It is: quantifiable, assessable, clear, calculable, determinate, finite, verifiable