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Medical Record, Patient Education, Patient Rapport PTP 641 Medical Surgical Physical Therapy Exam and POC.

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Presentation on theme: "Medical Record, Patient Education, Patient Rapport PTP 641 Medical Surgical Physical Therapy Exam and POC."— Presentation transcript:

1 Medical Record, Patient Education, Patient Rapport PTP 641 Medical Surgical Physical Therapy Exam and POC

2 Chart Review Documentation Initial Exams/Chart Reviews Daily Notes Progress Notes Discharge Summaries

3 Chart Review  Why perform a chart review?  For new eval  For treatment from last PT note  Face Sheet  History and Physical (H&P)  Consults  Orders/Referrals  Physician Progress Notes  ER Services Record  Nursing Vital Sign Flow Sheet  Meds  Nursing Intake Sheet  Labs, Diagnostic Test Results  Operative Report

4 Documentation  New Eval (as you review the chart, complete the form or take notes)  History  Face Sheet, H&P, Consults, Orders, Physician and Nursing Notes, ER/OR Reports, Lab Values, Diagnostic Results  Ask Nursing for clarification  Face to face discussion with the patient/family to clarify information or dwell deeper into an area of importance  Tests & Measures  Screens and then choose the most appropriate measurements  Document it was a screen, location, pt position, etc  Most PTs initiate some form of interventions (pt education, 1-2 ther ex, mobility)  PT Dx with prognosis  Recommendations – discharge/equipment and why  Goals  Plan of Care  Write the overall plan but last thing is to include a specific plan  Ex. Continue with general mobility, balance activities, endurance and strength of R LE.  Focus on hip precautions and check pulse ox with activity, assess strength of quads and DFs.

5 Documentation  Daily Note  SOAP format  Always document “Assessment” (Progression, regression or plateau) and address goals  Progress Note  Every 3-5 sessions the PT must write a progress note  Simple addendum to a daily note written by another PT or PTA OR PT is the person to provide care that day.  Overview of how the pt is progressing and why, what goals the pt is progressing towards or regressing or at a plateau – what to continue with for a POC  Discharge Summary  PT Dept policy is no discharge summary because pt’s are discharged and charts are broken down immediately OR electronic account is not accessible.  Check with clinical instructor or health system as a new grad

6 Communication  Nursing  How the patient performed  Physician  Other consults/referrals  CNA (Certified Nursing Assistant)  Mobility  Other Disciplines  OT, SLP, PTA  Case Manager – equipment, d/c plans  Social Worker – coping, d/c to SNF

7 Patient Care  Eval  Screens  Functional Mobility  Outcome Measure  Initiate HEP or treatment

8 Pt Care  Chart Review  History or Brief Questions  Measurements  Screens or repeated measurements  Procedural Interventions  Function or Exercise  Tolerance  Closing the session  Review therapy performed in the session  Pt satisfaction  Summarize overall goals  Perform HEP or next session

9 Patient Education

10 Is the Patient Receptive?  Pt’s State of Mind-Affective  Pain  Acute Stage of Disease/Disorder  Medication  Loss of Body Part  Disfigurement  Changes in Tissue  Impairments/Body Structure and Function  Functional Limitations/Activity Limitations  Disability/Participation Limitations  Contextual/Psychosocial  Coping

11 Quick Check During Examination  Relevant to conversation  Orientation  Person, Place, Time, Situation  Alertness  Alert to lethargy  Follow commands  Number of steps  Simple problem solving skills  Simple math, reasoning

12 Quick Check During Examination  Communication  Make needs known  Language  Learning Style  Educational needs  Written, auditory, pictures, kinesthetics  Learning barriers  HOH, legally blind, literacy

13 “Move Forward” (APTA)  Precautions/Contraindications  Watch Out versus Don’t Do  Therapeutic Exercise  Strength, Endurance, Balance, etc  Modifications  Mobility Training Instruction  Safety, Use of device, Fine tune movement  Disease Process  Prevention, modifications, if progressive, prevention  Discharge Destinations  Safety in the Home or Discharge Destination

14 HEP: “Make It Work” (Tim Gunn)  Fit into the day  Three times per day  Revolve around meal times  Simple to remember  Give only three to five exercises or points  Easy numbers to remember  Reps in 5’s, 10s  Position of patient  Ankle pumps: in supine, sit (open or closed chain)  Quad strength: quad set in supine, LAQ in sitting, mini-squats in standing

15 Information  Handouts  Booklets  Exercise Sheets  Journals/Logs  Pictures

16 Patient Rapport

17 Interpersonal Skills  Good verbal and nonverbal skills  Listening skills – the pt is the only thing in the world and you have their undivided attention  Knock prior to entering  Introduce Self  Student PT and why you are there  Address with title “Mr/Mrs/Ms”  Ask to call by first name or nickname  Write down “parking lot” list and address the items on the list  Respect Wishes  Respect Diversity

18 Interpersonal Skills  Dimensions of Patient Care  Respect Me As A Person  Relieve My Fears  Provide Me Comfort and Pain Relief  Involve My Family and Friends  Coordinate My Care  Treat Me As A Person, Not As An Episode  Give Me Predictive Information  Provide Me Access

19 Patient Rights  Advanced Directives  Confidentiality  Consents and Refusals  Pt Rights: The pt has the right to refuse  Pt Responsibilities: The pt has the responsibility to follow physician’s plan of care  Risks and Benefits

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