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Patient Care Skills.

module 1

define: Assessment the measurement or quantification of a varable or the placement of a value on something (do not confuse this with exam or eval. this is relating to the "SOAP")
define: Caregiver the person who is treating or working with a patient. (PT, PTA, Nurse, tech, aide, MD, RD, family mbr)
explain the difference btwn a patient vs. client. vs. consumer patient has a medical need 4 care, client is the term when the care is ellective (i.e. getting a massage for pleasure/relaxation), consumer could be considered who pays (i.e. the parent, but the child is receiving the care)
what are the three types of communication verbal (oral), nonverbal, written
define: documentation written or printed matter conveying authoritative info, records, or evidence
define: electrodiagnostic tests the use of an electrical current to assist with the diagnosis of a patient's condition.
define: evaluation a dynamic process in which the practiioner makes CLINICAL JUDGMENTS based on data gathered during the exam and IDs problems pertinent to patient/client mgmt.
define: examination the process of obtaining 1. HISTORY, 2. SYSTEMS REVIEW, 3. TESTS + MEASURES
define: goniometry the measurement of the ROM of a joint of the body
explain HIPAA? Health Insurance Portablility +Accountability Act of 1996-fed law enacted2 protect health info (PHI). any form- electronic, oral, or paper. ex) demographics (name, address, DOB, SSN), provision of HC to the individual, the past, present or future payment
define: kinesthesia the sense by which position, weight, and movmt are precieved
define: orthosis an orthopedic appliance used to support, align, prevent, or correct deformities or to replace the function of parts of the body (e.g., brace or splint)
define: outcome measure a quantifiable or objective means to determine the effectivenss of treatment or performance that is usually expressed in functional terms.
what is POMR? problem-oriented med record. a system developed 2organize a med record that uses a common list of pt. problems, a database, and a series of status/progress notes as its base. developed in 1960s. **note"status notes" in POMR can be written in SOAP format
define: proprioception perception mediated by the proprioceptors or proprioceptive testing; sensation and awareness about the movmts and posit of body parts or the body
define: prosthesis the artificial replacement of an absent body part (e.g. artificial limb)
define: radiograph an image or record produced on exposed or processed film thru radiography; a "roentgenogram"
what is SOAP? format for status notes- S: for subjective, O: objective, A: Assessment, P: Plan
define: stereognosis the ability to recognize the form (shape) of an object by touch
what is the joint comission? a private, non profit organization whose puprose is to encourage the attainment of uniformly high standards of institutional medical care
what is two point discrimination the ability to recognize or differentiate two blunt points when they are simultaneously applied to the skin.
identify the 2 models of disablement Nagi (1965) +World Health Organization- International Classification of Functioning (2001).
Describe Nagi and WHO ICF [Nagi is in CAPS, WHO ICF is in ( ).] they describes how PATHOLOGY (origin level/health condition) can lead2 IMPAIRMENTS (Organ level/body structure and function),FUNCTIONAL LIMITATIONS (person level/activity),+ DISABILITY (societal level/participation).
Y use WHO ICF over Nagi? more current is the WHO-ICF that takes into consideration the biologic, personal,and social and other domains. ICF common language can be used in goal setting, fucntional assessments, etc.
y do we have the two disablement models? theyre a universal language that measures outcomes +discuss health +impairment. this helps the caregiver ID biological processes in the body+enviro factors. it helps the PT treat cause +impact the impairment created.
give an ex of ICF for a baseball player's biceps tendonitis health cond: Biceps Tendonitis. Body Structure: Decreased muscle power, R shoulder pain. Activity (prsnl lvl): Difficulty throwing. Participation (societal): Baseball Plyr. (other domains- evironmental- baseball pract., school. Personal- 19yo, motivated.
list some pros of interprofessional collaboration: comprehensive approach-better treatment plng/better pt. outcomes. reduction in duplication/fragmetnation of prof. services. team is better able2address complex problems. enhances networking/ referrals 2other pros. team decision is better bc of dif input.
list some cons of interprofessional collaboration: process may overwhelm pt and reduce professional autonomy. may not produce better quality care. consulting takes time away from other pts. may reduce one-on-one relationship w/pt. collaboration may not be a value of the profession.
describe the process of orienting a pt. towards care? introduce yourself, verify pt is pt, verify diagnosis and referral, interview pt, informed consent, perform exam, establish goals and functional outcomes, inform pt of such, encourage pt to ask Qs.
what is culture the shared values, norms, tradions, customs, art, history, etc of a group of people
what is cultural competence a set of academic and interpersonal skills that ALLOW individuals to INCREASE their understanding and appreciation of cultural differences and similarities.
what is cultural diversity differences in race, ethnicity, language, nationality or religion. ex- a city is said to be culturally diverse.
what is cultural sensitivity an AWARENESS of the nuances of one's own and other cultures
what is culturally appropriate demonstarting both sensitivity to culutral differences and similarites as well as effectivenss in using cultural symbols (eye contact, closeness, etc).
what is Ethnic belonging to a common group, often linked by RACE, nationality or language. (larger than "race")
what is Race? a socially defined population that is derived from distinguishable PHYISCAL characteristics.
What are the elements of informed consent? descrip of pts. condition/diagnosis, plan of tx plan, risks, gains, prognosis, aternatives, questions, doucmentation! failure to fully inform a pt. is PROFESSIONAL NEGLIGENCE.
what are they types of notes and which format is used for each (SOAP/PCMM) inital note (pcmm), daily (soap), progress (SOAP or PCMM), discharge (either??)
name the S and O of the soap? subjective: sources of info from pt., family, caregiver, what the pt tells you, problem statement included, history in “S” of the note. objective (O): systems review + TM.
describe A and P of SOAP Assessment (A)-eval, diagnosis, prognosis. *(daily note- list pts improvements here)Plan (P) - Plan: expected outcomes, anticipated goals, interventions (communication, education plan, procedural intervention)
Describe PCMM: much more extensive than SOAP, typically used on EVAL! (1st time u see them!) -exam, eval, diag, prog, POC
list some rules of punctuation when documenting -avoid hypens -put semicolon instead of pt. “states” -replace “is” with :
list some rules of clarity when documenting -keep same tense -avoid vague terminology -be OBJECTIVE AND SPECIFIC + AVOID VAGUE (ex- supine, GH joint ROM)
what should you NOT do in notes? - Do not refer to yourself but the pt instead DON’T: use correction fluid/tape, erase, black out error, leave open lines.
how do we sign for now? SPT
give an ex of writting a verbal order? 09-12-12/18:30/Pt. may be FWB in PT. v.o. Dr. Ache/Tina Postrel, SPT.
what is a differential diagnosis? using a systematic process to compare and contrast the symptoms and distinguish one illness or condition from another, using education, knowledge, clinical experience.
what are the 2 primary methods to reach a differential diagnosis? 1-observation + interviews. 2-specific T+M!
what's the dif btwn eval and diagnosis? eval-dynamic process of ORGANIZATION + INTERPRETATION where the PT makes clinical judgements based on data gathered. diagnosis-LABEL that describes the lvls of diablement/impact of a cond. on function@ the level of the system and of the whole person.
general overview of steps when seeing a pt/ 1. review med record. 2. pt orientation. 3. informed constent. 4. PCMM!
what do you gather for the exam? History (subjective and objective info/data,) Systems Review ( observations of the pt, palaption of area,) Tests and Measures,
what do you need to write in the History? demographics, C/C, Pt goals, prior lvl of function, social Hx, employment, living enviro, general health(pts rating of self/1 yr), social/health habits, family Hx, Pts Medi/surgical Hx, functional/activity lvl, meds, growth +dev (peds), other tests.
time line dif btwn short term and long term goals ST-(interim) 2 wks. prep. component 4 long term goals. lead-in activity/sequential activities that produce cumlative effect. LT- (4 wks), desired outcome/max performance/functional outcome. should be revised/ modified based on pts. progress.
guidelines for communicating w/pts w/disabilities ID pt. NOT the disease. do not increase volume, correct or speak for pt. ask if they need assistance- they will tell you if they do. if so, ask for specific instructions. if hearing impaired, use tactile or viusal cueing b4 speaking. avoid term "victim"
sentinel event vs. potential adverse event sentinel (adverse) is an injury caused as a result of medical mgmt rahter than condition or diagnosis (i.e. faulty equip install). potentially- "close call, near miss"
active vs latent error Active- usually caused by individual, effects become apparent quickly and latent is delayed, usually caused by third party (i.e. the ex of the faulty equip install, not secured and happen after install team leaves)
what are the 5 rights/ right pt, drug, time, route, dose (PDTRD- Please Dont Throw Ron's Drug's)
what's the Joint Commission/ sets standards on QUALITY and SAFETY. private, non-profit organization that comes and surveys facilities via "tracer methods" following select pts' course thruout the facility.
Created by: tpostrel