FSA Lecture Week 2

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FSA Lecture Week 2 by Mind Map: FSA Lecture Week 2

1. Chapter 3

1.1. Medical terminology

1.1.1. A Afferent Conducting toward a structure Analgesia "Without pain" - acts in various ways to affect the peripheral and central nervous system, including: Anesthesisa "Without sensation" (drug induced loss of consciousness during which patients are not arousable, even by painful stimulation) Anterior or ventral Front of the body Aphasia Lack of speech (loss of language ability due to mental injury) Arthralgia "Joint pain" - swelling, injury, or infection of the joints Arthritis Joint inflammation Arthrodesis Fusion of a joint (artificial induction of joint ossification between two bones via surgery) Arthroscopy Inspection of joint with a scope Ataxia Lack of coordination

1.1.2. B-C Bilateral Affecting both sides Bradykinesia "Slow movement" - used to refer to slowly-progressing diseases Cardiomegaly Enlargement of the heard Cephalad Toward the head Cerebromalacia Softening of the brain Chondroma Cartilaginous tumor (benign, encapsulated with a lobular growing patter) Chondromalacia Softening of cartilage Contralateral Opposite sides Costochondral Pertaining to the rib and rib cartilage Craniotomy Surgical opening of the skull (part of the skull-a bone flap is removed in order to access the brain

1.1.3. D-L Dispnea Difficult or bad breathing Dorsal Pertaining to the back of your body Dysphagia "Difficult to eat" - refers to a patient that has difficulty swallowing Encephalitis Inflammation of the brain Erythema Abnormal redness of the skin Hemiplegia Paralysis of one half of the body Hypertension Abnormally high blood pressure (chronically elevated) Hypoglycemia Abnormally low blood sugar Intercostal Between the ribs

1.1.4. M-Z Meningioma Tumor of the meninges Meniscectomy Removal of cartilaginous tissue that makes up the meniscus Myopathy Disease of a muscle Neurology Study of the nervous system and/or nervous disorders Osteoma Tumor of the bone Phlebitis Inflammation of a vein (usually in the legs) Subclavicular Beneath the clavicle Subcutaneous Beneath the skin Suprapubic Above the symphysis pubis Symphysis pubis Fusion of the pubis bones medially Tendinitis Inflammation of a tendon (usually due to overuse)

2. Chapter 2

2.1. Effective writing style

2.1.1. Accuracy This information is permanent, so do not: Lie Exaggerate Guess at... Include irrelevant data

2.1.2. Brevity Use standard abbreviations Some facilities permit sentence fragments If a flow sheet or table is used for the results of tests and measures... Additional information demonstrating the therapist's clinical judgment must be documented in addition

2.1.3. Clarity Avoid sudden shifts of tense

2.1.4. Punctuation Hyphens can be confused for minus signs and should be avoided Semicolons are very useful in reducing word redundancy Colons can be used instead of "is"

2.1.5. Correcting errors Do not use correction fluid or tape Put a single line through the error Write the date Initial above the error

2.1.6. Signing notes (Authentication) Use legal name Follow with initials indicating your status as a therapist

2.1.7. Referring to yourself If necessary, do so in third person

2.1.8. Blank/empty lines These can render your note vulnerable to tampering

2.1.9. General format for writing physician notes in a chart: date/time/order v.o. physician's name/therapist's signature, PT Once written, the physician cosigns

3. Chapter 1

3.1. Methods of documentation

3.1.1. (P)SOAP Note Commonly used throughout the country Acronym: (Problem) Subjective Objective Assessment Plan

3.1.2. Patient/Client Management Note Used by some clinicians as physical therapy practitioners become familiar with the Guide to Physical Therapy Practice History Systems review Tests and measures Evaluation Diagnosis Prognosis Plan of care

3.2. Purposes of documentation

3.2.1. Record Helps to legally protect the rights of the therapist and patient Patient care notes are considered legal documents Ensures legitimate testimony from the PT if/when the need arises

3.2.2. Communication Goal is to provide consistency and coordination among the services provided by various health care professionals Communicates: Results of examination Therapist's evaluation Diagnosis Prognosis Therapist's expected outcomes and anticipated goals Intervention plan

3.2.3. Advocacy Assisting the patient in obtaining insurance coverage for physical therapy Must justify the need for therapy services Third party payers make decisions based on therapy notes

3.2.4. Discharge Planning

3.2.5. Helps to encourage as well as reflect structured clinical decision making

3.2.6. Quality assurance/improvement

3.2.7. Outcomes research Consistency of format is important

3.2.8. Education Informs others about the services that physical therapy can provide

3.2.9. Demonstration of Compliance

3.3. Types of Notes

3.3.1. Initial Written after the first patient examination and evaluation Documents the examination, evaluation, diagnosis, prognosis, and plan of care

3.3.2. Progress Written periodically, reporting: Results of re-examination Results of re-evaluation Changes in prognosis Changes in plan of care

3.3.3. Discharge Written when therapy is discontinued or the patient is discharged After final examination and evaluation Addresses: Results of final examination and evaluation Outcomes and goals achieved Summary of the interventions received Final disposition

3.4. Process of clinical decision making

3.4.1. Examination SOAP Gathering information from: Patient/Client Management Nature of data

3.4.2. Evaluation This is where the therapist's clinical decision-making processes are evident SOAP Assessment section Patient/Client Management Evaluation section

3.4.3. Diagnosis Includes a discussion of the relationship of the patient's functional deficits to the patient's impairments Can include a discussion of the relationship of the patient's disability to functional deficits and impairments SOAP Assessment section Patient/Client Management Diagnosis section

3.4.4. Prognosis Can include: Predicted level of improvement that the patient will be able to achieve and the predicted amount of time to achieve that level of improvement Therapist's professional opinion of the patient's rehabilitation potential Future therapy that the therapist believes will be needed Proposed duration of therapy Projected final outcomes, if not listed in the Expected Outcomes part of the Plan of Care Plans for discharge may be listed in subsection SOAP Assessment section

3.4.5. Plan of care Includes: Expected outcomes Anticipated goals Interventions Some may include with prognosis SOAP Plan of Care section

4. Chapter 4

4.1. Abbreviations

4.1.1. Symbols 2° secondary 1° primary → progressing toward, approaching ↔ to and from +, &, et. and % percent / per # number, pounds (5# weight = 5 lbs weight) - or (-) minus, negative + or (+) plus, positive = equal Δ change ~ approximately a(bar) before p(bar) after s(bar) without c(bar) with // parallel or parallel bars ↑ Up ↓ Down ♀ Female ♂ Male +1 (+2, etc.) assistance (assistance of 1 person given; also written"assistance of 1."

4.1.2. A-Ai A: assessment ABI acquired brain injury afib atrial fibrillation A-line arterial line A-V arteriovenous AAA abdominal aortic aneurysm AAROM active assistive range of motion Abd or abd abduction ABG arterial blood gases ac before meals AC joint acromioclavicular joint ACL anterior cruciate ligament ACTH adrenocorticotrophic hormone Add or add adduction ADL activities of daily living ad lib at discretion adm admission, admitted AE above elbow AFO ankle foot orthosis AIDS acquired immune deficiency syndrome AIIS anterior inferior iliac spine

4.1.3. Ag-Az AJ ankle jerk AK above knee ALS amyotrophic lateral sclerosis a.m morning AMA against medical advice amb ambulation, etc ANS autonomic nervous system ant anterior AP anterior-posterior ARDS adult respiratory distress syndrome ARF acute renal failure AROM active range of motion ASA aspirin ASAP or asap as soon as possible ASCVD arteriosclerotic cardiovascular disease ASHD arteriosclerotic heart disease ASIS anterior superior iliac spine assist. asisitance, assistive AVM arteriovenous malfomation

4.1.4. B B/S bedside BBB bundle branch block BE below elbow BID or bid twice a day bilat. or B bilateral, bilaterally BK below knee BM bowel movemen BOS base of support BP blood pressure bpm beatsper minute BR bedrest BRP bathroom priviliges BS breath sounds or bowel sounds BUN blood urea nitrogen

4.1.5. C-Cn C centrigrade C&S culture and sensitivity CA cancer, carcinoma CABG coronary artery bypass graft CAD coronary artery disease CAT computerized axial tomography cal calories CBC complete blood cell count CC, C/C chief complaint CF cystic fibrosis CHF congestive heart failure cm centimeter CMV cytomegalovirus CNS central nervous system

4.1.6. Cm-Cz c/o complains of CO cardiac output CO2 carbon dioxide cont. continue COPD chronic obstructive pulmonary disease COTA certified occupational therapy assistant CP cerebral palsy CPAP continuous positive airway pressure CPR cardiopulmonary resuscitation CRF chronic renal failure CSF cerbrospinal fluid CV cardiovascular CWI crutch walking instructions CXR chest x-ray Cysto cystoscopic examination

4.1.7. D-E D/C discontinued or discharged dept. department DIP distal interphalangeal DJD degenerative joint disease DM diabetes mellitus DNR do not resuscitate DO doctor of osteopathy DOB date of birth DOE dyspnea on exertion DTR deep tendon reflex DVT deep vein thrombosis Dx diagnosis E.R. emergency room ECF extended care facility ECG, EKG electrocardiogram ED emergency department EEG electroencephalogram EENT ear, eyes, nose, throat EMG electromyogram eval. evaluation ext. extension

4.1.8. F-G FBS fasting blood sugar FEV forced expiratory colume FH family history flex flexion FRC functional residual capacity ft. foot, feet (measurement) FUO fever of unknown origin FVC force vital capacity FWB full weight bearing fx fracture g gram GB gallbladder GO gastrointestinal GSW funshot wound GYN gynecology

4.1.9. H H&H, H/H hematocrit and hemoglobin H&P history and physical H, Hgb hemoglobin HA, H/A headache HCVD hypertensive cardiovascular disease HEENT head, ear, eyes, nose, throat HEP home exercise program HIV human immunodeficiency virus HNP herniated nucleus pulposus h/o history of HOB head of bed h, hr. hour HR heart rate Hct hematocrit hs at bedtime ht. height Ht hematocrit Htn or HTN hypertension Hx history

4.1.10. I-K KUB kidney, ureter, bladder KJ knee jerk kg kilogram kcal kilocalories KAFO knee-ankle-foot orthosis IV intravenous IS incentive spirometry IRDS infant respiraotry distress syndrome inf inferior indep independent in. inches IMV intermittent madatory ventilation imp. impression IM intramuscular IDDM insulin-dependent diabetes mellitus ICU intensive care unit IADL instrumental activities of daily living I&O intake and output

4.1.11. L LP lumbar puncture LOS length of stay LOC lossof consciousness, level of consciousness LMN lower motor neuron LE lower extremity LBP low back pain LBBB left bundle branch block lb. pound lat lateral L or l. liter L left

4.1.12. M m meter MAP mean arterial pressure max maximal MD medical doctor MED minimal erythemal dose Meds. medications mg milligram MI myocardial infarction min minimal min. minute ml milliliter mm millimeter MMT manual muscle test mod moderate mo. month MP, MEP metacarpophalangeal MRSA methicillin-resistant Staphylococcus aureus

4.1.13. N NWB non-weight bearin NSR normal sinus rhythm NPO or npo nothing by mouth noc night, at night nn nerve NIDDM non-insulin-dependent-diabetes mellitus N.H. nursing home nasogastric NG or ng neg. negative NDT neurodevelopmental treatment

4.1.14. O oz. ounce OTR occupational therapist (used to follow official signature of the occupational therapist OT occupational therapy, occupational therapist ORIF open reduction, internal fixation O.R. operating room O.P. outpatient OOB out of bed od once daily OBS organic brain syndrome OB obstetrics OA osteoarthritis O: objective

4.1.15. P-Pn PNI peripheralnerve injury PNF proprioceptive neuromuscular facilitation PMH past medical history p.m. afternoon P.H. past history PERRLA pupils equal, round, reactive to light, and accommodation p.o by mouth per by/through PEEP positive end expiratory pressure PE pulmonary embolus PCL posterior cruciate ligament pc after meals para paraplegia PA posterior/anterior P.A. physician's assistant P: plan, intervention plan, plan of care P poor

4.1.16. Po-Pz POMR problem-oriented medical record pos. positive poss possible post posterior post-op after surgery PRE progressive-resistive exercise pre-op before surgery prn whenever necessary, as often as necessary PROM passive range of motion PSIS posterior-superior iliac spine PT physical therapy, physical therapist PT/PTT prothrombin time/partial thromboplasitn time Pt., pt. patient PTA physical therapist assistant PTA prior to admission PTB patellar tendon bearing PVD peripheral vascular disease PWb partial weight bearing

4.1.17. Q-R Rx intervention plan, prescription, therapy RT respiratory therapist, respiratory therapy RROM resistive range of motion RR respiratory rate ROS review of systems ROM range of motion R/O or r/o rule out RN registered nurse resp respiratory, respiration reps repetitions rehab rehabilitation re: regarding R.D. refistered dietician RBC red blood cell count RBBB right bundle branch block RA rheumatoid arthritis R right qt. quart qn every night qh every hour qid four times a day q every

4.1.18. S Sx symptoms sup superior stat. immediately, at once spec specimen S/P status post (e.g., "S/P hip fx" means "Pt. fx her hip in the recent past." SOB shortness of breath SOAP subjective, objective, assessment, plan SNF skilled nursing facility SLR straight leg raise SLP speech-language therapist SLE systemic lupus erythematosus SI(J) sacroiliac (joint) sig directions for use, give as follows, let it be labeled SED suberythemal dose sec. seconds SC joint sternoclavicular joint SCI spinal cord injury SACH solid ankle cushion heel

4.1.19. T TV tidal volume Tx traction TUR/TURP transurethral resection tsp. teaspoon TPR temperature, pulse, and respiration t.o telephone order TN tonic neck reflex TM(J) temporomandibular (joint) TKA total knee arthroplasty tid three times daily TIA transient ischemic attack ther ex therapeutic exercise THA total hip arthroplasty TENS, TNS transcutaneous electrical nerve stimulator/stimulation tbsp. tablespoon TBI traumatic brain injury TB tuberculosis tab tablet

4.1.20. U-Z UA urine analysis UE upper extremity UMN upper motor neuron URI upper respiratory infection US ultrasound UTI urinary tract infection UV ultraviolet VC vital capacity VD venereal disease v.o. or VO verbal orders vol. volume v.s. vital signs w/c wheelchair W/cm^2 watts per square centimeter WBD white blood cell count wk. week WNL within normal limits wt. weight X number of times performed y/o or y.o. years old yd. yard yr. year