Mod 4-7 Flashcards

1
Q

Eval note Problem description

A

chief complaint (w/ med & PT Dx)
contradindications
med. record info
functional limitations

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2
Q

Eval note Subjective description

A

current/past med. history
complaints/symptoms
prior level of function
patient roles & goals

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3
Q

Eval note Objective description

A

info from exam that’s reproducible & reference for outcomes
interventions provided & pt. response
pt/fam education given*

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4
Q

Eval note Assessment description

A

PT’s interpretation/comparison of S& O data
identify/relate impairment, AL, PR
goals & justification
prognosis & rehab potential

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5
Q

Eval note Plan description

A

plan for intervention activities
frequency/duration of services
equipment needs
estimated discharge plan

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6
Q

when documenting pain, obtain:

A

pain level
location of pain
which pain profile used

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7
Q

indirect interventions (3)

A

coordination/communication, documentation, pt/client instruction

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8
Q

Therapeutic Exercise examples

A

strength, endurance, ROM/flexibility exercises
gait for distance/endurance

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9
Q

Neuromuscular Re-education examples

A

reeducate movement, balance, coordination, kinesthesia, posture, proprioception (seated, standing)

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10
Q

Gait Training examples

A

gait or stair/curb negotiation
include assistive device, assist level etc

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11
Q

Therapeutic Activity examples

A

functional training
transfer, body mechanics, bed mobility, lifting, I/ADLs, w/c management, gait for distance

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12
Q

Massage examples

A

effleurage, petrissage, tapotement, friction, vibration

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13
Q

Manual Therapy examples

A

mobilization, manipulation, manual lymph drainage, manual traction, myofascial release

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14
Q

Physical & mechanical agents examples

A

ultrasound, electrical stimulation (TENS), paraffin bath, biofeedback, hydrotherapy, mechanical traction, vasopneumatic device, hot/cold pack

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15
Q

validity

A

ability to measure what it’s supposed to

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16
Q

reliability

A

extent of consistency & error-free
interrater vs intrarater (same person)

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17
Q

Types of Vital Signs

A

HR/pulse (bpm)
BP (mm Hg)
SaO2 (%)
RR (breaths/min)
(also pain rating)

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18
Q

A-F Formula Components
& 5 Component Method

A

Actor (Who)
Behavior (What)
Condition (How)
Degree (How)
Expected Time Frame (goals only*) - (When)
Function (Why)

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19
Q

daily goals

A

for critical thinking practice, in assessment
-relate to any level of ICF

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20
Q

STGs/anticipated goals

A

relate to impairment level
-in assessment

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21
Q

LTGs/ functional outcomes

A

relate to activity/participation level

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22
Q

Privacy Act of 1974

A

pt.’s right to obtain copy of medical records

23
Q

HIPAA

A

health insurance portability & accountability act

24
Q

HIPAA Privacy Rule

A

national standards to protect, use and disclose PHI

25
HIPAA Security Rule
(under the privacy rule) protects electronic PHI
26
FERPA
Family Education Rights & Privacy Act student provides written permission to disclose edu. records
27
Who determines ethical responsibilities in PT?
APTA
28
Who determines legal responsibilites in PT?
HIPAA & state/federal laws
29
insurance fraud
intentionally billing for items/services that weren't provided billing services for higher reimbursement than was provided
30
insurance abuse
billing for unnecessary items excessively charging for a service misusing billing codes (upcoding)
31
Anti-Kickback Statute
prohibits the offer/payment/solicitation of something of value to induce/reward referrals or to generate business
32
Stark Law
prohibits physicians from referring Medicare patients to an entity which they have a financial relationship
33
provider of liability/malpractice insurance
Healthcare Providers Service Organization (HPSO)
34
Incident report examples
adverse treatment outcome (burn, fall, skin tear) procedural breakdown (confidentiality breach) catastrophic event (medical error)
35
CMS
center for medicare/medicaid services
36
PMH
previous medical history
37
IFSP
individualized family service plan
38
IEP
individualized education plan
39
RTC
return to clinic
40
mod I
modified independent requires AD to complete activity
41
Supervision (S)
requires vc or is safety concern
42
SBA
stand by assist requires close watch of therapist w/ verbal/visual cues
43
CGA
contact guard assist therapist makes contact w/ pt due to unsteadiness
44
min A
minimum assist pt. performs 75-99% of task
45
mod A
moderate assist pt performs 25-75% of task
46
max A
maximum assist pt. performs less than 25% of task
47
dependent (D)
therapist provides 100% of physical assistance
48
ICD
international classification of diseases
49
THA
total hip arthroplasty
50
AFO
ankle foot orthosis
51
FIM
functional independent measure
52
MHP
moist hot pack
53
f/u
follow up
54