WEEK 12 Flashcards
what are some components of documentation?
- Patient identification information, dates
- The care that was provided
- Details of the care provided and by whom
- Outcomes of care
- Recommendations and plan for the proposed intervention
- Chart review and initial assessment
- Analysis of the assessment findings
- Detailed treatment plan and all changes to the plan
- Summary of the episode of care when care has been completed (discharge note)
What is the purpose of documenting?
1) Legal reasons – professional accountability, evidence of events, decisions, interventions, and plans.
2)Assurance of continuity of care
3)Assurance of quality care
4) Reimbursement
Explain the “Why” in the Basics of treatment planning
Education piece for the client
- Explain that injuries heal and timelines
- Explain the benefits of therapy
Explain the “When” in the Basics of treatment planning
At which frequency will the care be delivered?
Examples:
- weekly
- bi-weekly
-daily
-monthly
Explain the “Where” in the Basics of treatment planning
Where will the treatment sessions take place?
Examples:
- clinic
- hospital
-school
- Home
- classroom
- pool
- gym
Explain the “What” in the Basics of treatment planning
Examples of treatments carried out by the OTA PTA
- Walking re-education following a below-knee amputation
- Teaching one-handed techniques to dress lower and upper body following a stroke
- Teaching how to safely use a 4 wheel walker to prevent falls
- Therapeutic group session for stress management
- Exercice classes post knee or hip surgery
Explain the “Who” in the Basics of treatment planning
Who is going to provide the treatment?
- Therapist only
- Therapist and OTA PTA
- Mostly OTA PTA
Who else might be involved to support the treatment?
- Teacher
- parents
- caregivers
What does a basic treatment plan include:
1)Patient/client’s strengths
2)Patient/client’s treatment goals
3)Unique and detailed plan of treatment
4)Steps to achieve therapy goals
What is the role of the OTA PTA with outcome measures?
- can administer outcome measures that have been assigned to support the evaluation
what is an example of an Outcome Measure?
Wong-Baker Faces - Pain Rating Scale
An outcome measure should only be used if it has been tested for:
Validity: how accurately the test actually measures supposed to measure.
Reliability: overall consistency of the test
Responsiveness: the extent to which an instrument can measure change when change has occurred
What is outcome measures?
A tool used to assess a client/patient’s current status
Result is used to objectively determine a baseline, track progress and guide treatment
Can be used throughout a client/patient’s rehab trajectory
What does it mean to establish the client’s baseline
- What is their “normal”?
- Develop a clinical or working diagnosis and/or prognosis
- Develop a detailed treatment plan
- Determine need to use tools to track progress
What is included in an initial assessment
Medical history
The client’s primary complaint/concern
Physical examination
Review of test results and any other relevant information
Identification of patient/client’s goals and needs
Who is responsible of completing the initial assessment?
Therapist
What is a treatment plan?
- A written, comprehensive document
- Aims at addressing the client/patient’s health issue
- Outlines the agreed-upon course of action between the health care provider and the client/patient.
- Patient/client centered
- Dynamic in nature
