Week 4 Lectures Flashcards
(41 cards)
ICF MODEL
ICF MODEL
Setup of ICF
-Health Condition
-Body Function
& Body Structures
-Activity
-Participation
-Environmental Factors
-Personal Factors
Difference between activity and participation?
Activity- Execution of a task by an individual
ACTIVITIES OF DAILY LIVING
Participation- Involvement in a life situation
Difference between Health Condition and Body Functions or Structures
Health condition- disease or disorder
Body Functions and Structure- problems that stem from the health condition
Example: Health condition is stroke, body structure and function could be right side hemapheresis
Examples of personal factors.
Age
Gender
Education
Past experiences
Examples of environmental factors
- Social attitudes
- Physical space
Do they have handrails in the house, or stairs
Order of the Patient-Client Management Model?
- Examination
- Evaluation
- Diagnosis
- Prognosis/ Plan of Care
- Intervention
- Outcome
Examination
- )History
- )Systems Review
- )Tests and Measures
Screening, tests, process of taking history.
Vitals, flexibility, ROM.
H
Body Screening Systems
- Cardiovascular/ Pulmonary System- the assessment of heart rate, respiratory rate, BP, and edema
- Integumentary System- the assessment of the skin
- Musculoskeletal System- the assessment of gross symmetry, gross ROM, gross strength, height, and weight
- Neuromuscular System- general assessment of gross coordination movement and motor function
What is evaluation?
Our judgement based on what we gathered in systems review, history
What is diagnosis?
- Identify impact of a condition on function; categorize impairements
- Interpreting data from exam and eval
Difference between medical diagnosis and physical therapy diagnosis?
Medical Dx- identification of a disease, disorder, or condition
PT Dx- identification of the impact of a condition on function at the level of the whole person
What is prognosis?
Determination of the level of optimal improvement that may be attained through intervention and the amount of time required to meet that level
What is intervention?
Procedures and techniques appropriate to diagnosis to produce change
What is outcome?
Measure of intended results
Can measure change in:
- Impairments
- Activity limitations
- Participation limitations
- Risk reduction
INTRO TO DOCUMENTATION
INTRO TO DOCUMENTATION
Why do we document?
- Legal record
- Communication
- Advocacy/ documenting medical necessity
- Discharge planning
- Demonstrating clinical decision making
- Quality assurance and improvement process
- Research
- Demonstrating compliance
Principles of note writing?
- Accuracy
- Brevity
- Clarity
What is an initial note?
- Taken at the first visit only
- Includes the initial eval and plan of care
What is a daily note?
Recorded at each visit.
May do daily note with eval
What is a progress note/ re-evaluation?
Done every 10 visits/ every 30 or 60 days
Done when patient condition changes unexpectedly or does not progress as expected.
Do you need to do a daily note with discharge?
Yes, so you can bill
If intake forms are used, only the pertinent information is included in the history or __________
_____
What is a systems review?
Brief screening examination that allows the therapist to scan the patient’s body systems and determine areas of intact function and dysfunction in each of the following systems
