Potpourri
Components of this are: Examination, Evaluation, Diagnosis, Prognosis, Plan of Care.
What is Initial Evaluation / Examination?
Abnormalities in body structure or function such as pain or decreased strength or increased tone.
What are body function/structure (impairments)?
How you start a statement
What is "patient reports" or "patient states?"
What are Systems Review and Tests & Measures?
The autistic boy.
The words in the acronym "SOAP"
What are subjective, objective, assessment and plan?
Examples include inability to walk without a device, difficulty bathing, and needs assist with transfers.
What are activity limitations?
When the patient tells you all about what symptoms they have
What is current condition / chief complaints or history?
Pt. is able to take his right knee from straight to a bend of 85 degrees.
What is "R knee AROM 0-85 degrees?"
Jason is wheelchair-bound.
What is Jason uses a wheelchair?
Three consumers of physical therapy notes.
Who are: patients, 3rd party payers, legal system, PT, PT aide, PT student, PT supervisor, other members of healthcare team?
Examples include: decreased strength B quadriceps, decreased R knee flexion
What is body function/structure (impairments)
When you ask a patient about their cardiovascular system, GI health, eyes, ears, nose, throat, etc.
What is Review of Systems?
BP 120/80, HR 76, RR 24 are included in this.
What is Systems Review? or What are vital signs?
The handicapped person.
What is the person with a disability.
Where you document your PT note.
What is the medical record or electronic medical record (EMR)?
Example includes a high school student being unable to access classes during time frame given due to use of crutches.
What is participation restriction?
What does the patient wish to accomplish in PT?
What are patient goals?
The total hip in room 122.
What is the patient with a total hip replacement in room 122?
What is the name of the electronic medical record (EMR) system that we will be using in this course?
What is webPT?
Examples include insurance, motivation, values, and culture.
What are personal factors?
The acronym used to remember what information ask about a patient's symptoms.
What is OLDCARTS?
What is "Pt. amb. with antalgic gait and decreased knee flexion, RLE?"
The crazy woman.
What is the woman with a mental health condition.