Term
| The examination: three subsets |
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Definition
| History, Systems Review and Tests and Measures |
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Term
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Definition
| Demographic, current condition/chief complaints, patient goals, prior level of functions, social history, employment status, living environment, general health status, social/health habits, family health history, patient's medical/surgical history, functional status/activity level, medications, growth and development, other clinical tests the patient has experienced |
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Term
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Definition
1.Cardiovascular/Pulmonary 2.Integumentary 3.Musculoskeletal 4.Nueromuscular 5.Communication 6.Affect 7.Cognition 8.Learning barriers 9.Learning style 10.Educational needs.
*cardiopulmonary is the only one with exact measurements. others are listed as impaired or not impaired with brief description. |
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Term
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Definition
| name, address, admission date, d.o.b, sex, dominant hand, race, ethnicity, language, educational level, advance directive preferences, referral source, and reasons for referral therapy. |
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Term
| Current conditions/chief complaints |
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Definition
| the onset date of the problem, any incident that caused or contributed to the onset of the problem, prior history of similar problems, how the patient is caring for the problem, what makes the problem better and worse, and any other practitioner the patient is seeing for the problem. |
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Term
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Definition
| patient/client and sometimes family goals for therapy. |
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Term
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Definition
| level of function prior to the most recent onset current conditions or complaints. If the patient has a chronic condition, this includes the level of function prior to the most recent onset or exacerbation of his/her symptoms. |
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Term
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Definition
| cultural and religious beliefs, persons with whom the patient lived prior to admission and will live after discharge, available social and physical supports available to the patient now and that will be available after discharge, and the availability of the caregiver. |
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Term
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Definition
| pt works full time or part time, inside or outside of the home, is retired or is a student. |
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Term
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Definition
| assist. devices and equipment, type of residence, info. about environment (stairs, ramps, etc.), past use of community services (home health, meals on wheels, hospice, homemaking services, mental health, previous therapy;PT,OT,Resp.T,SLP) |
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Term
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Definition
| patients rating of health and whether the patient has experienced any major life changes during the proceeding year. |
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Term
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Definition
| alcohol, smoking, exercise |
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Term
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Definition
| heart disease, htn, stroke, diabetes, cancer, psychological conditions, arthritis, osteoporosis, and other conditions. |
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Term
| functional status/activity level |
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Definition
| bed mobility, transfers, gait, self-care, home management, and community and work activities that apply to the pt.'s current situation or condition |
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Term
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Definition
| this includes developmental hx and is most applicable to pediatric pts. |
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Term
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Definition
| this includes laboratory or radiology tests, and the dates and findings of those tests. |
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Term
| Where is ht. and wt. documented? |
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Definition
| In the musculoskeletal section of the systems review. |
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Term
| Subcategories of neuromuscular in systems review |
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Definition
| gait, locomotion, balance, motor function |
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Term
| Cognition orientations documented in systems review |
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Definition
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Term
| During which portion of the evaluation would the therapist note decision to refer pt. elsewhere |
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Definition
| Systems review; reason for referral to other area of health care is noted here. This would be used in place of the Progress of Discharge Notes. |
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Term
| Which section of the P/C management note contributes most to the determination of the Dx, prognosis, and plan of care? |
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Definition
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Term
| Tests and measures headings categories |
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Definition
| 1.types of tests and measurements performed 2.areas of the body and functional skills |
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Term
| 3 common mistakes in recording data from tests and measures |
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Definition
| 1.failure to state the affected body part 2.failure to state measurable information 3.failure to state the type of whatever it is that is being measured or observed |
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