Medical Record, Patient Education, Patient Rapport

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 • 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

Medical Record, Patient Education, Patient Rapport