Introduction to Physical Therapy Unit 2 – Flashcards

Clarity Acute Precise Brevity Appropriate medical terminology Writing Style: end sentences; avoid hyphens; write in past tense; write in third person; if possible, use headings to separate sections of the note Objective: Use numbers to quantify your statements; describe any equipment used Prompt: do not put off, memories are not as reliable as we would like to think Do not allow for tampering: do not leave empty lines, draw a line through them; correct errors Correcting: single line through error date it your initials "error" written above it no white-out...why not? Signing a Note: use your legal signature include credentials (PTA, SPTA) designate supervising PT on every note use only black or blue ink

The American Physical Therapy Association Guidelines on Physical Therapy Documentation of Patient/Client Management uses; initial examination/evaluation, visit/encounter, reexamination and discharge or discontinuation summary

1. Database=current and past information about the patient 2. Problem list 3. Identification of a specific treatment plan by each provider on the case 4. Assessment of effectiveness of the treatment plan across time Book 1) Formation of a database (current and past information about the patient) 2) Development of a specific, current problem list 3) Identification of a specific treatment plan (developed by each caregiver) 4) Assessment of treatment plan effectiveness

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1. To keep record of patient care 2. To communicate between health care professionals 3. Justifies payment of services to third party payers 4. Assists in decision-making-how? 5. Provides data for quality assurance 6. Provides data for research 7. Method to organize the information gathered or produced from a treatment

Subjective Statements Response to previous treatment Pain level (JCAHO requirement) Prior level of function Emotions, attitudes, expressed beliefs Lifestyle and home situation Patient's goals Patient's complaints Assessment Patient (A) will transfer (B) from bed to wheelchair (C) independently (D) in one week (E) to be able to eat meals with family (F). Patient (A) will improve (B) right knee extension (C) from -10o to 0o (D) within 4 treatment sessions (E) to return to football practices (F). Patient will improve running distance on the treadmill from 3 miles to 6 miles within 3 weeks to begin training for 10K race. Patient will report decreased morning low back pain from a 6/10 to a 3/10 in 3 treatment sessions to perform personal hygiene. A: Patient demonstrated eagerness to work hard to enact improvements in both shoulder and hip deficits however, needed constant reminders to monitor her safety precautions for the left THA when sitting and during bed mobility. Patient will benefit from review of proper ADL modifications to ensure optimal hip safety. A: Patient will continue to benefit from skilled intervention to address muscular imbalances in rotator cuff muscles and scapular stabilizers so patient is able to lift objects overhead at work. Patient continues to require therapist motivation to perform TherEx program. A: PT has good rehab potential Objective: Hip Clearing reproduces pain (L) knee Objective: Gait training w/ crutches, 10% PWB RLE for 50 ft. x 2 w/ min A x 1. Plan: Will initiate OT post-op per critical pathway. Subjective: States hx of COPO since 2010. Assessment: Pt. was difficult to assess due to lack of cooperation as demonstrated by closing his eyes & crossing his arms when given a command. Plan:Will be seen by PT as an O.P. beginning 3x/wk. & progressing prn. S: Past experience of PT for low back pain w/o relief of pain. Objective: Rx this date: training in w/c propulsion & management, transfer training sliding board w/c↔mat & sit↔supine. Pt. required two rest breaks to complete all the activities. A: Pt. will demonstrate normal gait pattern within 2 wks. to enable her to amb for functional distances. Subjective: Pt. reports pain (L) ankle while putting limited weight on LLE. Objective:Strength: 1/5 in (R) lower trapezius. (Ms strength is 1 on a scale of 0 to 5). Plan: Talk to PT about progressing AROM exercises to PRE. Assessment: ↑ AROM (R) shoulder to WNL within 2 wks. to enable patient to reach items in her overhead cabinets. Plan: Will inquire if Pt. can be referred to a dietician. Objective: Pulsed US underwater at 1.5 W/cm2 to (R) wrist. (US=ultrasound) Assessment: Pt. will be (I) in donning/doffing prosthesis within 1 wk. in order to stand. Subjective: Pt. states she lives w/ husband in her own home. Plan: Provide instruction to the Pt. in w/c management and propulsion. Subjective:Pt. states he would like to return home with his wife following D/C.

In the S section you have to ask about their functional goals. It will be very difficult to write an STO if you do not have the information. In other words, if you do not ask about what the patient wants to get back to doing, you cannot write an STO (you may be able to write an assessment statement, but not an STO). In the O section, you want to remember that your interventions should address what function they are meeting. It's a little easier here since you have to write things like, standing transfer with weak knee stabilized, etc., but this still address function. Maybe a better example would be with gait training. You wouldn't say patient learned to use an assistive device; instead something like patient walked 20 feet using a three point crutch gait pattern. (Something like that anyway). And of course you cannot write a good A statement if you do not tie everything back to function. Why are you treating this patient? It can't be as simple as saying they are weak, they are in pain, etc. It must tie in to function. As the slideshow stated, you won't write when you are actually in the clinic, but it is important that you are always thinking about how your interventions are meeting functional goals. Don't worry about the P section, unless you feel the need to specifically state that a patient needs to work on a particular functional skill, i.e, on the next visit begin 50 pound floor to above-head lifting.

Long-Term Goals Written for extended time frames, i.e., months Help to plan the treatment and guide the POC Short-Term Goals Written in shorter time frames, i.e., treatment sessions or weeks Direct treatment to specific needs and problems

Audience: Patient when possible or family member Behavior : What is the activity? Condition: Circumstances involved with the behavior Degree: The measurable portion Expected time: How long will it take? Function: What should they be able to do when goal met? Function is relative and determined by patient.

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This refers to the preferred way an individual processes information and describes a person's typical mode of thinking , remembering or problem solving. A number of cognitive styles have been identified and studied over the years.

This specifically deals with characteristic styles of learning; have been widely applied in school settings and seem to be useful in terms of creating teacher awareness of individual differences in learning.

One of the most fundamental concepts in learning is transfer, i.e., the ability to apply something learned in one situation to another setting. Transfer is defined operationally as improved performance on one task as a result of something acquired on a previous task. This could be any type of skill (e.g. memory, sensory-motor, problem-solving, reasoning, etc.).

• Leaning is dependent upon the capacities of the learner. • Learning is a function of conditions of practice and/or instructions imposed upon the learner. • Learning materials and tasks are easily mastered when they are meaningful to the learner. • Learning is facilitated by knowledge of results/feedback. • The transfer of learning is dependent upon the similarities of the learning tasks and/or the similarities of principles and work methods that can be applied in the transfer situation. • Learning is related to the degree and quality of learners motivation. • Learning is also related to the learner's aspiration and experience. • Active participation is still better than passive learning. Meaningful learning is still more effective than rote memory

• Adults are autonomous and self-directed. • Adults bring established beliefs, values, opinions with them to any learning environment. • Most adult learners are goal oriented. • Adult learners prefer relevant topics. • Adults do learn from their mistakes, but they can be overly sensitive to failure. • Adults like to learn practical information. • Adults favor different senses for learning. • Adults learn best when they succeed. • Adults learn better when they can monitor their own progress. • Adults learn best when what they are to learn is customized for them. Adults tend to be problem-centered in approaching learning.

This model classifies students according to their preferences on scales derived from psychologist Carl Jung's theory of physiological types. Learning Style: Characteristics: Extrovert (E) try things out; focus on the outer world of people Introvert (I) think things through; focus on the inner world of ideas Sensors (S) practical; detail oriented; focus on facts and procedures Intuitors (N) imaginative; concept-oriented; focus on meanings and possibilities Thinkers (T) skeptical; tend make decisions based on logic and rules Feelers (F) appreciative; tend to make decisions based on personal and human considerations Judgers (J) set and follow agendas; seek closure even with incomplete data Perceivers (P) adapt to changing circumstances; resist closure to obtain more data

This model classifies students as: Sensing learners (concrete, practical, oriented toward facts and procedures) or intuitive learners (conceptual, innovative, oriented toward theories and meanings) Visual learners (prefer visual representations of presented material - pictures, diagrams, flow charts) or verbal learners (prefer written and spoken explanations) Indicative learners (prefer presentations that proceed from the specific to the general) or deductive learners (prefer presentations that go from the general to the specific) Active learners (learn by trying things out, working with others) or reflective learners (learn by thinking things through, working alone) Sequential learners (linear, orderly, learn in small incremental steps) or global learners (holistic, systems thinkers, learn in large leaps) The dichotomous learning style dimensions of this model (sensing/intuitive, visual/verbal, inductive/deductive, active/reflective, and sequential/global) are not either/or categories. A student's preference on a given scale (e.g. for inductive or deductive presentation) may be strong, moderate, or almost nonexistent, may change with time, and may vary from one subject or learning environment to another.

Kolb's Learning Style Model This model classifies students as having a preference for 1) concrete experience or abstract conceptualization (how they take information in), and 2) active experimentation or reflective observation (how they internalize information) The four types of learners in this classification scheme are:Divergers, Assimilators, Convergers, Accommodators

This method classifies students in terms of their relative preferences for thinking in four different modes based on the task-specialized functioning of the physical brain. The four modes or quadrants in this classification scheme are: Quadrant A, Quadrant B, Quadrant C, Quadrant D

This theory theory states that there are at least seven different ways of learning anything, and therefore there are "seven intelligences": Body/Kinesthetic, Interpersonal, Intra-personal, Logical/Mathematical, Musical/Rhythmic, Verbal/Linguistic and Visual/Spatial. In addition most all people will have the ability to develop skills in each of the intelligences, and to learn through them. However, in education we have trended to emphasize two of the "ways of learning": logical/mathematical and verbal/linguistic.

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A characteristic question of this learning type is "Why?" Type 1 learners respond well to explanations of how course material relates to their experience, their interests, and their future careers. To be effective with Type 1 students, the instructor should function as a motivator. Their greatest strength is imaginative ability. Individuals with this style tend to be in the humanities and liberal arts. Counselors, organizational development consultants, and personnel managers often have this style. Concrete, Reflective

A characteristic question of this learning type is "What?" Type 2 learners respond to inform atino presented in an organized logical fashion and benefit if they have time for reflection. To be effective, the instructor should function as an expert. Their greatest strength lies in the ability to create theoretical models. Individuals with this style tend to be in the basic sciences and mathematics. Abstract, Reflective

A characteristic question of this learning style is "How?" Type 3 learners respond to having opportunities to work actively on well-defined tasks and learn by trial-and-error in an environment that allows them to fail safely. To be effective, the instructor should function as a coach, providing guided practice and feedback. Their greatest strength lies in the practical application of ideas. Individuals with this style tend to be in the physical sciences and engineering fields. Abstract, active

Concrete, active A characteristic question of this learning style is "What if?" Type 4 learners like applying course material in new situations to solve real problems, To be effective, the instructor should stay out of the way, maximizing opportunities for the students to discover things for themselves. Their greatest strength is doing things, in carrying out plans, experiments, and becoming involved in new experiences. They tend to be risk-takers more than the other three styles. Their educational background is often in technical or practical oriented jobs, often marketing and sales.

Part of HBDI (left brain, cerebral). Logical, analytical, quantitative, factual, critical

Part of HBDI left brain, limbic). Sequential, organized, planned, detailed, structured

Part of HBDI right brain, limbic). Emotional, interpersonal, sensory, kinesthetic, symbolic

HBDI (right brain, cerebral). Visual, holistic, innovative

Felder-Silverman These Learners learn by direct interaction with the material; prefer group communication

These learners like to think about the material; prefer individual or very small group communications Felder-Silverman

Felder-Silverman These learners are better able to remember images they have seen (charts, graphs, pictures

Felder Silverman These are better able to remember written or spoken works

Felder-Silverman This type of learner is detailed oriented and practical with a preference for concrete facts and real world applications

Felder-Silverman This type of learner have creative disposition and are drawn to the theoretical and abstract

Felder-Silverman This type of learner prefer learning linearly with logical steps

Felder-Silverman This type of learner prefer a holistic approach and seem to learn almost randomly by fitting pieces together into a big picture

Multiple Intelligences Model This intelligence is related to physical movement and the knowing/wisdom of the body. Including the brain's motor cortex, which controls bodily motion. Body/kinesthetic intelligence is awakened through physical movement such as in various sports, dance, and physical exercises as well as by the expression of oneself through the body, such as inventing, drama, body language, and creative/interpretive dance.

Control of "voluntary" movements Control of "preprogrammed" movements Expanding awareness through body The mind an body connection Mimetic abilities Improved body functioning

Multiple Intelligence Model This intelligence operates primarily through person-to-person relationships and communication. Interpersonal intelligence activated by person-to-person encounters in which such things as effective communication, working together with others for a common goal, and noticing distinctions among persons are necessary and importent.

Effective verbal/non-verbal communication Sensitivity to other's moods, temperaments, motivations, and feelings Working cooperatively in a group Ability to discern other's underlying intentions and behavior "Passing over" into the perspective of another Creating and maintaining synergy

Multiple intelligence Model This intelligence relates to inner states of being, self-reflection, metacognition (i.e. thinking about thinking), and awareness of spiritual realities. Intra-personal intelligence is awakened when we are in situations that cause introspection and require knowledge of the internal aspects of the self, such as awareness of our feelings, thinking processes, self-reflection and spirituality.

Concentration of the mind Mindfulness Metacognition Transpersonal sense of the self Awareness and expression of different feelings Higher-order thinking and reasoning

Multiple Intelligence Model Often called "scientific thinking" this intelligence deals with inductive and deductive thinking/reasoning, numbers, and the recognition of abstract patterns. Logical mathematical intelligence is activated in situations requiring problems solving or meeting a new challenge as well as situations requiring pattern discernment and recognition

Abstract pattern recognition Deductive reasoning Performing complex calculations Inductive reasoning Discerning relationships and connections Scientific reasoning

Multiple Intelligence Model This intelligence is based on the recognition of tonal patterns, including various environmental sounds, and on a sensitivity to rhythm and beats. Musical/rhythmic intelligence is turned on by the resonance or vibration al effects of music and rhythm on the brain, including such things as the human voice, sounds from nature, musical instruments, percussion instruments, and other humanly produced sounds.

Appreciation for the structure of music Sensitivity to sounds Sensing characteristic qualities of tone Schemes or frames in the mind for hearing music Recognition, creation, and reproduction of melody/rhythm

Multiple intelligence Model This intelligence, which relates to words and language both written and spoken, dominates most Western educational systems. Verbal linguistic intelligence is awakened by the spoken word, by reading someone's ideas, thoughts, or poetry, or by writing one's own ideas, thoughts, or poetry, as well as by various kinds of humor such as "plays on words", jokes, and "twists" of the language.

Understanding order and meaning of words Explaining, teaching, and learning Memory and recall Convincing someone of a course of action Humor "Meta-linguistic" analysis

Multiple Intelligence Model This intelligence, which relies on the sense of sight and being able to visualize an object, includes the ability to create internal mental images/pictures. Visual/spatial intelligence is triggered by presenting the mind with and/or create unusual, delightful, and colorful designs, patterns, shapes, and pictures, and engaging in active imagination through such things as visualization guided imagery, and pretending exercises.

Active imagination Finding your way in space Graphic representation Accurate perception from different angles Forming mental images Image manipulations Recognizing relationships of objects in space

You learn best when information is presented visually and in a written language format. In a classroom setting, you benefit from instructors who use the blackboard or overhead projector to list the essential points of a lecture, or who provide you with an outline to follow along with during lecture. You benefit from information obtained from textbooks and class notes. You tend to like to study by yourself in a quiet room. You often see information "in your mind's eye" when you are trying to remember something

To aid recall, make use of "color coding" when studying new information in your textbooks or notes. Using highlighter pens, highlight different kinds of information in contrasting colors. Write out sentences and phrases that summarize key information obtained from your textbook and lecture. Make flash cards of vocabulary words and concepts that need to be memorized. Use highlighter pens to emphasize key points on the cards. Limit the amount of information per card so your mind can take a mental "picture" of the information. When learning information presented in diagrams or illustrations, write out explanations for the information. When learning mathematical or technical information, write out in sentences and key phrases your understanding of the material. When a problem involves a sequence of steps, write out in detail how to do each step. Make use of computer word processing. Copy key information from your notes and textbook into a computer. Use the print-outs for visual review. Before an exam, make yourself visual reminders of information that must be memorized. Make "stick it" notes containing key words and concepts and place them in highly visible places --on your mirror, notebook, car dashboard, etc.

You learn best when information is presented visually and in a picture or design format. In a classroom setting, you benefit from instructors who use visual aids such as film, video, maps and charts. You benefit from information obtained from the pictures and diagrams in textbooks. You tend to like to work in a quiet room and may not like to work in study groups. When trying to remember something, you can often visualize a picture of it in your mind. You may have an artistic side that enjoys activities having to do with visual art and design.

Make flash cards of key information that needs to be memorized. Draw symbols and pictures on the cards to facilitate recall. Use highlighter pens to highlight key words and pictures on the flash cards. Limit the amount of information per card, so your mind can take a mental "picture" of the information. Mark up the margins of your textbook with key words, symbols, and diagrams that help ou remember the text. Use highlighter pens of contrasting colors to "color code" the information. When learning mathematical or technical information, make charts to organize the information. When a mathematical problem involves a sequence of steps, draw a series of boxes, each containing the appropriate bit of information in sequence. Use large square graph paper to assist in creating charts and diagrams that illustrate key concepts. Use the computer to assist in organizing material that needs to be memorized. Using word processing, create database software to further organize material that needs to be learned. As much as possible, translate words and ideas into symbols, pictures, and diagrams

You learn best when physically engaged in a "hands on" activity. In the classroom you benefit from a lab setting where you can manipulate materials to learn new information. You learn best when you can be physically active in the learning environment. You benefit from instructors who encourage in-class demonstrations, "hands on" student learning experiences, and field work outside the classroom.

To help you stay focused on class lecture, sit near the front of the room and take notes throughout the class period. Don't worry about correct spelling or writing in complete sentences. Jot down key words and draw pictures or make charts to help you remember the information you are hearing. When studying, walk back and forth with textbooks, notes, or flash cards in hand and read the information out loud. Think of ways to make your learning tangible, i.e. something you can put your hands on. For example, make a model that illustrates a key concept. Spend extra time in a lab setting to learn an important procedure. Spend time in the field (e.g. a museum, historical site, or job site) to gain first-hand experience of your subject matter. To learn a sequence of steps, make 3'x5' flash cards for each step. Arrange the cards on a table top to represent the correct sequence. Put words, symbols, or pictures on your flash cards - anything that helps you remember the information. Use highlighter pens in contrasting color to emphasize important points. Limit the amount of information per card to aid recall. Practice putting the cards in order until the sequence becomes automatic. When reviewing new information, copy key points onto a chalkboard, easel board, or other large writing surface. Make use of the computer to reinforce learning through the sense of touch. Using word processing software, copy essential information from your notes and textbook. Use graphics, tables, and spreadsheets to further organize material that must be learned. Listen to audio on a media player while exercising, Make your own audio files containing important course information.

The patient's Primary and treatment diagnosis Physician's orders The patient's barriers to treatment and their resolution The patient's consent to treatment The plan of care, which includes goals, interventions, proposed frequency and duration and discharge Short term and long term goals Risk or benefit of treatment.

Necessary information can be built into a "check-off" format in which answers to questions such as Does the patient consent to treatment?" would be checked of as "yes," "no" or unable to respond". If "unable to respond" is checked, an explanation must be given before moving on to the next area in the record. Patient information is readily available from other disciplines, including laboratory results, x-ray examinations, etc and that interdepartmental communication is facilitated by improved readability and the ability of multiple users to access information simultaneously.

The length of time to document is not much shorter than handwritten documentation, initial and ongoing staff training in the use of the computer program, is required and the software and hardware may be inadequate or may malfunction

Lawrence Weed developed the concept of ______________ in the 1960s. This system is used by many health care facilities throughout the United States, some of which have developed their own variations. This system is based on a list of patient problems, a database, and a series of status (progress) notes designated as the "initial," interim or ongoing and "discharge" notes. When all departments or service units of a facility use POMR record keeping, a higher quality of patient care may be anticipated, better communication among the caregivers is more likely to occur, and better decisions about the patient's treatment can be made.