Lecture 1 Flashcards
The guide
APTA developed to reflect best practice and to unify language surrounding patient care
Living document
Standardizes terminology
Who is the guide for?
Members of PT profession
Healthcare policy makers
Third party payers (ex: Medicare/Medicaid)
What does the guide include?
Describes examination and evaluation process
Test and measures
Selection process for interventions
How to use outcome measures
Patient/client management
Patient definition
Medical model, individual who is receiving medical care and treatment
Acted upon, passive role
Client definition
Embraces shares decision-making, active role in treatment
Originated from mental health terminology
Patient and Client Management Model
Examination
Evaluation
Diagnosis
Prognosis
Intervention
Outcomes
Episode of care
Services provided for a particular diagnosis
Can include other providers
Examination
Must happen during initial appointment
Obtaining a history, doing a systems review, and tests/measures
Data gathering
History
Part of exam step
Current problem
Medical info
Social history
Past and present info that impacts current problem
Systems Review
Step 2 of exam
Status of 4 key systems. CVP, SKIN, MSK, NM
Communication: A + O (x4). Alert and oriented
Tests and measures
Used to confirm or reject a hypothesis
Support PT clinical judgements about diagnosis, prognosis, and plan of care
Evaluation
Step 2 of patient/ client model
Data assimilation
What is the problem, what is the cause and can it be helped with PT?
Identify contributing factors
Diagnosis
Step 3
Label used to categorize problem so you can determine care/prognosis
Identifying the impact of a condition on function
Described in terms of impairments, activity & participation limitations
Prognosis
Step 4
Expected outcome of a disease
Predicted level of improvement
Described in intervention and amount of time
Setting goals for recovery
Plan of care is determine by
Goals
Interventions
Duration and Frequency
BID
Twice per day
QD
once per day
Intervention
Step 5
What you choose to do to help you patient achieve their goals
9 major categories
Coordination, communication, and documentation must occur
Documentation
Any entry into the patient health record
Subjective
Objective
Assessment
Plan
Categories of intervention
Instruction
Airway clearance
Assistive technology
Biophysical agents
Functional training
Skin repair
Manual therapy
Motor function training
Therapeutic exercise
W/c
Wheelchair
Outcomes
Step 6
Actual results, related to goals, assessing progress
Not always positive, so need to reevaluate
ICF model
How mobility tasks fit into a person’s overall health. Helps us to know which mobility tasks to focus on
Dynamic Systems Theory
How a person accomplishes a mobility task
Person and environment work together to impact task
