Patient Care Activities Flashcards
(36 cards)
Orientation of the client
Do not assume they know why they are there!
Each session should have some kind of orientation
Who are you?
- What is your name?
- What is your title?
- Why you think they are there or ask them why
- What you do
Is it the right patient, diagnosis, doctor?
- review intake form/medical records
- confirm, don’t ask again
- avoid yes/no questions, you find out more when they talk
Look and listen as you assess
ECHOWS
(E)stablish rapport
- if they don’t trust you, they won’t be back
(C)hief complaint
- what brings you here?
- do you notice other things?
(H)ealth and occupational history
- comorbidities
- medications
(O)ther, psychosocial, motivation, client factors
(W)rap up
(S)ummary
- verify what you think
As the OT what are you responsible for?
Selecting appropriate assessments and tests
- based on diagnosis
* confirm the ICD 10
* develop therapeutic diagnosis
- based on prognosis
- based on other issues
Make this goal a functional outcome: “Pt will achieve full AROM in 6 weeks.”
Pt will complete UE dressing independently
Make this goal a functional outcome: “Johnny will pay attention for 10 minutes.”
Johnny will stay on task for 10 minutes to participate in story time.
Johnny will stay on task for 10 minutes with 4 or fewer prompts.
How do you communicate with clients who are deaf?
translator (person or electronic)
pictures
writing
How do you communicate with someone with a cognitive delay?
Family interview
Simplify
- grading
- pictures
- fewer steps
- repeat instructions
How do you communicate with a client who refuses or doesn’t like you?
Inform, don’t threaten
Ask why… –> interest inventory –> occupational profile
Leave
Problem oriented medical record (POMR)
Often used in education and psych
Arena eval
Problems are numbered in order of importance
Only works with a true team
Source oriented medical record (SOMR)
More traditional form of documentation
Types of documentation we typically see
Evaluations/assessments
Treatment plan/goals and objectives
Daily notes
Progress notes
Doctor notes/letters
Discharge note
Referrals
Exercise programs
Home programs
Electronic medical record (EMR)
SOAP: Subjective
The patient appeared sad
“I hate you, I hate this place.”
Pain scale
SOAP: Objective
The patient was laughing and smiling when she entered the room.
Client was offered 4 activities to promote balance and refused to attempt any.
Pain measure
SOAP: Assessment
Professional opinion based on fact
Due to the recent fall, fear may be a reason the client is not willing to attempt activities.
Client does not appear to be motivated, she seems more interested in spending time with her visitors.
SOAP: Plan
What the client is going to do in therapy in the future.
At next therapy session, we will start with 3 side support to alleviate fear.
Will discuss with daughter the need to limit visitors to afternoon so the client will attend therapy.
Why is documentation important?
It is a legal document.
It’s how we make money.
Primary mode of communication
It it isn’t documented, it didn’t happen
There’s a 3 year period for lawsuits.
General documentation knowledge
Keep it factual
Only document the important stuff, keep it simple
Make sure it flows, shows progress, and why you are making certain decisions
Document on time
Be legible
Only use approved abbreviations
Leave nothing blank
If you cosign for a COTA, know what you are signing
General patient eval
Gather subjective and objective information
Find the primary problem
Find the cause
Previous level of function and treatment
Current level of function
Pain
Medication
General areas to assess
General appearance
Skin
Ambulation or posture
Mobility
Balance, coordination, control
- static and dynamic
Devices
Joints
Deformities
Edema
Pulse
General tests
MMT
AROM, PROM, AAROM
- goniometer
- eyes
- computer
Joint integrity
Reflexes
Cardiopulmonary
- pulse
- BP
- respiration
Functional vs. physical
Mental and cognitive
Developmental
Things to consider
X-ray
MRI
Psychological testing
Hearing
Patient and family education
Patient should always know diagnosis.
Family doesn’t always have to know.
If pt has a DNR, make sure to have a copy.
HIPAA
Health Insurance Portability and Accountability Act
Notice of privacy
No information that is identifiable.
- sign in sheets
- room number
- name
Designed to
- give clients access and control over health information
- protect against the use and release of health information
- establish safeguards to assure privacy
What happens if you violate HIPAA?
Single violation - $100 fine
Multiple violations of an identical requirement in a single year - up to $25, 000 fine
Wrongful disclosure - 1 year in prison and $50,000 fine
Wrongful disclosure under false pretenses - 5 years in prison and $100,000 fine
Wrongful disclosure with intent to profit or harm - 10 years in prison and $250,000 fine
