medical record, patient education, patient rapport
DESCRIPTION
Medical Record, Patient Education, Patient Rapport. PTP 641 Medical Surgical Physical Therapy Exam and POC. Chart Review Documentation Initial Exams/Chart Reviews Daily Notes Progress Notes Discharge Summaries. Chart Review. Why perform a chart review? For new eval - PowerPoint PPT PresentationTRANSCRIPT
Medical Record, Patient Education, Patient Rapport
PTP 641
Medical Surgical Physical Therapy Exam and POC
Chart Review
DocumentationInitial Exams/Chart Reviews
Daily NotesProgress Notes
Discharge Summaries
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
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.
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
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
Patient Care Eval
Screens Functional Mobility Outcome Measure Initiate HEP or treatment
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
Patient Education
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
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
Quick Check During Examination Communication
Make needs known Language Learning Style
Educational needs Written, auditory, pictures, kinesthetics
Learning barriers HOH, legally blind, literacy
“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
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
Information Handouts Booklets Exercise Sheets Journals/Logs Pictures
Patient Rapport
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
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
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