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Definition
enacted at federal state and local levels by legislative branches of government
ie. practice act |
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Definition
| regulations developed by government agencies (medicare/medicaid) |
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Definition
| case or judge-made law that is derived from what is customary |
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Definition
| government prosecutes individuals on behalf of society |
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Definition
| area of law dealing with private complaints for wrongdoing |
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Term
| Medical/Legal Issues concerning PT: |
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Definition
Consent
Standards for medical documentation
contents for medical records
risk management
policies and procedures
HIPAA |
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Term
| Laws Regarding the Maintenance of Medical Record: |
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Definition
3/5/7 rule
3- years for all records concerning general care
5- years for all records concerning medicare
7- years for records concerning a dispute |
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Term
| Completions of Additions to the Medical Record: |
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Definition
has to be done within 14 days of episode
should be done by the end of the working day
(after surgery it should be done immediately)
all additions should be dated, timed, and signed |
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Term
| What are the components of the SOAP note? |
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Definition
Subjective
Objective
Assessment
Plan |
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Term
| Subjective Section of Soap Note |
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Definition
summary of patient's statements plus basic observations
also any information gathered from others with connection to the patient |
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Term
| Objective Section of SOAP note |
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Definition
observations that can be measured
add any new data, interventions used for the session, and the physical or mental responses to the treatment |
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Term
| Assessement portion of the SOAP note |
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Definition
response of the patient to the treatment session overall
overall changes
goals met, or improvement made
new goals |
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Term
| Plan portion of SOAP note |
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Definition
includes frequency and duration, or changes made related to assessment, changes in interventions
preparation for the next phase of the protocol |
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Term
Use of Systems Review
(part of the P/C Management Note) |
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Definition
reports the result of a brief examination or screening of the CV/Pulmonary, Integumentary, Musculoskeletal, and Neuromuscular systems
first hands on part of the examination |
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Term
| How are sections of the systems review reported? |
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Definition
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| What is included in a Systems Review? |
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Definition
cardiovascular/pulmonary
integumentary
musculoskeletal
neuromuscular
cognition
learning barriers
*not usually a plan or care or discharge note |
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Term
| What are the parts of a Patient/Client Management note? |
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Definition
history
systems review
tests and measures
evaluation
diagnosis
prognosis
plan of care
*initial eval and exam should be included |
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Term
What is a physical therapist?
(elevator speech) |
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Definition
| A PT's job is to recognize impairment or dysfunction and use that information to improve mobility and strength. PT's help to improve ROM, strength, coordination, endurance, and alleviate pain. In PT, it is often the goal to help the client return to daily work or leisure activities. |
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| What are some important rules for writing in the medical record? |
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Definition
be timely and relevant, use black or blue ink, medical terminology, third person language
don't skip lines
date and initial always |
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Term
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Definition
| a planned, systematic process to reduce and/or eliminate the probability that losses will occur in a specific setting |
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| What are the components of risk management? |
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Definition
risk identification and loss prevention
loss reduction
risk financing |
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Term
| Report of an Incident is ____ and is placed in ____. |
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Definition
not part of the medical record
administrative documentation only |
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Term
| What are the six sections of the initial eval? |
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Definition
reason for referral
activities
impairments
assessment
goals
plan of care |
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Term
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Definition
| information made actionable |
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Term
| Deductive vs. Inductive reasoning |
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Definition
Deductive : If... then
Inductive: basis of scientific model, opposite of if... then |
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Term
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Definition
known, and can quantify
not tangible (ie. IQ) |
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| What are the steps of evidence based practice? |
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Definition
identify
gather info
critique
apply
evaluate outcomes |
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Term
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Definition
Pathology
Impairment
Functional limitation
Disability |
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Term
| What did Jette focus on? (modified disablement model) |
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Definition
demographics
physical/social environment
behavioral aspects |
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Term
| What did WHO add to the disablement model? |
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Definition
| handicap ---> social disadvantages |
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