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

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

Chart Review Why perform a chart review? Face Sheet 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 Progress Note Discharge Summary 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 Physician CNA (Certified Nursing Assistant) 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