Lecture #4 (Examination and Assessment)

Question 1

How does a clinician know what deficiencies need to be addressed in a rehab patient?

Answer 1

An assessment examination

Question 2

How should the goals be written?

Answer 2

To note that there is a plan in place to address the deficiencies noted in the exam

Question 3

True or false:

It is always important to do a full exam with patients–whether or not they are acute or chronic.

Answer 3

False–acute patient may not be able to tolerate a full examination. Gather the information that you can without making them too painful, and then you can gather the rest later

Question 4

What types of ROM should be documented in the exam? How should it be documented?

Answer 4

PROM, AROM, AAROM, and pain free ROM

**also flexibility if applicable, It should be documented by using a goniometer (degrees) or tape measure

Question 5

How are joint mobs documentated?

Answer 5

4-5= hypermobile
3= normal mobility
1-2= hypomobile

Question 6

What are other things that need to be documented on the exam in addition to ROM and flexiblity?

Answer 6

Joint laxity/mobility, special tests, muscle strength tests, and neurological tests

Question 7

What will most likely be used to make RTP or release/discharge decisions?

Answer 7

Functional testing

Question 8

What is the rehab diagnosis?

Answer 8

The problems identified in the exam (and final assessment( that need to be overcome in order to return a patient to their previous function

Question 9

Is the patient progressing faster/slower than you anticipated? Is the patient motivated? Working hard? Is there a problem affecting other parts of rehab? Questions such as these are used to gauge what? Where would the answers to these questions be put in a SOAP note?

Answer 9

These are gauging progress and potential. They would be answered in the assessment (A) part of the SOAP note.

Question 10

What should be included in the plan section of the SOAP note?

Answer 10

How the clinician will try to address the problemes noted in the assessment (the rehab diagnosis)

Question 11

Do insurance companies like functional or non-functional goals better?

Answer 11

Functional–if a goal cannot be made functional, you need to question whether or not that goal is really needed. Also, a goal cannot be made unless a deficiency was noted in the exam

Question 12

True or false:

At least 1/2 of rehab goals should be functional.

Answer 12

True!

Question 13

True or false:

All LTGs should be functional.

Answer 13

True!

Question 14

How often should goals be reassessed?

Answer 14

Every two weeks

Question 15

How can we objectively measure strength?

Answer 15

MMT, dynometer, weight, body weight, functional, isokinetic dynomometer

Question 16

How can we objectively measure ROM?

Answer 16

Goniometer, tape measure, inclinometer, joint play, percentage

Question 17

When writing the plan for the treatment, what should the outline of the program include?

Answer 17

Frequency and duration of the treament, evolving as the patient status changes, address the goals of treatment, a and any home instructions/patient plan away from rehab

Question 18

What would an assessment post-modality treatment be used to assess?

Answer 18

Patient’s pain level

Question 19

What is the only way to make the program achieve its desired effect?

Answer 19

Constantly assess and change the program as needed on the info received during the assessment

Question 20

As the program progresses, functional activities should be added in order to prepare the patient for what?

Answer 20

Their pending RTP. Functional testing should be sport specific and position specific. Specialized skills should also be addressed.

Question 21

True or false:

You could be the best clinician in the world, but if you cannot document, you are unemployable

Answer 21

True

Question 22

What is a document that accesses the progress of the patient and notes that all goals have been assessed why a patient is being released from the rehab program?

Answer 22

Discharge summary

Question 23

Why is tracking data associated with a rehab program becoming increasingly necessary in this profession?

Answer 23

ATs can justify their ability to charge a third-party payors for thier services……also being used by insurance companies to curtail costs of rehab but still ensure good treatment is being given.

Question 24

True or false:

ATs are above the curve in achieving good outcomes in less time

Answer 24

TRUE!!!!! :)

-We can push, motivate, etc. to progress the patient