Lumbar precautions - ANSWER-no BLT! side bending, lifting/forward bending at spine,
or twisting
posterior hip precautions - ANSWER-no internal rotation, adduction past midline, or
flexion at hip past 90
weight-bearing precautions - ANSWER-NWB, TT, PWB, WBAT, FWB
MEDICAL designation of the amount of weight permitted to be placed through a
patient's affected extremity
sternal precautions - ANSWER-given after sternotomies (CABG, transplants, valve
replacement)
decreases sternal wound complications
varies based on hospital/rehab center
usually involve weightlifting restrictions, restrictions on shoulder movement, and
restrictions on pushing down through arms
issues with sternal precautions - ANSWER-not based on any evidence
reinforces fear of activity
typically leads to pt needing more assist from staff and family, may lead to pt getting
discharged to rehab instead of home if no one can help pt at home
gait patterns (4 point, 3 point, 2 point) - ANSWER-4 point - really inefficient, use with
crutches, canes, walking sticks (pattern if L leg is affected side: R crutch, L leg, L crutch,
R leg)
3 point - walker, affected, unaffected (could also do w NWB and crutches)
2 point - typically for NWB and crutches
gait - step to vs step through - ANSWER-step-to: good for partial weightbearing,
unaffected foot steps to be beside the affected foot
step-through: symmetrical gait pattern, good for progression
alternative to sternal precautions - ANSWER-"keep your move in the tube"
keep arms close to body to decrease stress placed through sternum
keep arms in front of you
, ascending and descending stairs pattern (cane) - ANSWER-A: cane, cue to offload,
strong leg, weak leg
D: cane, weak leg, cue to offload, strong leg
ascending and descending stairs pattern (crutch) - ANSWER-A: cue to offload, strong
leg, weak leg, crutch
D: crutch, weak leg, cue to offload, strong leg
ascending and descending a platform step - ANSWER-A: walker, cue to offload, strong,
weak
D: walker, weak, cue to offload, strong
alternative methods for stairs - ANSWER-stairs with a shower chair
butt-scooting
important guidelines to follow when documenting in a medical record (4) - ANSWER-
accuracy, brevity, clarity, efficiency
Accuracy - ANSWER-NEVER record false, exaggerated, or made-up data
incorrect spelling, grammar, punctuation can be misleading
brevity - ANSWER-state info concisely but do not use unwarranted abbreviations - even
pt!
clarity - ANSWER-wording should be immediately clear to the reader
make sure all abbreviations are consistent and clear, following department policy
efficiency - ANSWER-daily notes should take 5-10 mins, evals take 15-20 mins with
experience
develop this skill last
notes on note writing - ANSWER-no 1st person
only use objective statements
sign every note
should include portions of the pt/client management model (impairments, activity
limitations, participation restrictions)
point-of-service documentation - ANSWER-notes are completed partially during a
session
may improve efficiency and accuracy but remember to communicate with pt why you
are typing
main types of PT notes (5) - ANSWER-initial evaluation
daily treatment note
progress note
discharge note
other patient encounter
initial evaluation - ANSWER-created to establish a plan of care
includes PMH, CMH, current complaints, examination procedures, assessment of
procedures, interventions completed, goal creation, planned interventions,
recommended frequency and duration, and other components
daily treatment note - ANSWER-updated subjective information, newly completed
examination procedures if present, treatment interventions, assessment of those
interventions on pt function
progress note - ANSWER-required to be completed per insurance guidelines
recommended to be completed prior to other medical appointments
assessment related to progress, reassessment of goals, updates to plan of care
or twisting
posterior hip precautions - ANSWER-no internal rotation, adduction past midline, or
flexion at hip past 90
weight-bearing precautions - ANSWER-NWB, TT, PWB, WBAT, FWB
MEDICAL designation of the amount of weight permitted to be placed through a
patient's affected extremity
sternal precautions - ANSWER-given after sternotomies (CABG, transplants, valve
replacement)
decreases sternal wound complications
varies based on hospital/rehab center
usually involve weightlifting restrictions, restrictions on shoulder movement, and
restrictions on pushing down through arms
issues with sternal precautions - ANSWER-not based on any evidence
reinforces fear of activity
typically leads to pt needing more assist from staff and family, may lead to pt getting
discharged to rehab instead of home if no one can help pt at home
gait patterns (4 point, 3 point, 2 point) - ANSWER-4 point - really inefficient, use with
crutches, canes, walking sticks (pattern if L leg is affected side: R crutch, L leg, L crutch,
R leg)
3 point - walker, affected, unaffected (could also do w NWB and crutches)
2 point - typically for NWB and crutches
gait - step to vs step through - ANSWER-step-to: good for partial weightbearing,
unaffected foot steps to be beside the affected foot
step-through: symmetrical gait pattern, good for progression
alternative to sternal precautions - ANSWER-"keep your move in the tube"
keep arms close to body to decrease stress placed through sternum
keep arms in front of you
, ascending and descending stairs pattern (cane) - ANSWER-A: cane, cue to offload,
strong leg, weak leg
D: cane, weak leg, cue to offload, strong leg
ascending and descending stairs pattern (crutch) - ANSWER-A: cue to offload, strong
leg, weak leg, crutch
D: crutch, weak leg, cue to offload, strong leg
ascending and descending a platform step - ANSWER-A: walker, cue to offload, strong,
weak
D: walker, weak, cue to offload, strong
alternative methods for stairs - ANSWER-stairs with a shower chair
butt-scooting
important guidelines to follow when documenting in a medical record (4) - ANSWER-
accuracy, brevity, clarity, efficiency
Accuracy - ANSWER-NEVER record false, exaggerated, or made-up data
incorrect spelling, grammar, punctuation can be misleading
brevity - ANSWER-state info concisely but do not use unwarranted abbreviations - even
pt!
clarity - ANSWER-wording should be immediately clear to the reader
make sure all abbreviations are consistent and clear, following department policy
efficiency - ANSWER-daily notes should take 5-10 mins, evals take 15-20 mins with
experience
develop this skill last
notes on note writing - ANSWER-no 1st person
only use objective statements
sign every note
should include portions of the pt/client management model (impairments, activity
limitations, participation restrictions)
point-of-service documentation - ANSWER-notes are completed partially during a
session
may improve efficiency and accuracy but remember to communicate with pt why you
are typing
main types of PT notes (5) - ANSWER-initial evaluation
daily treatment note
progress note
discharge note
other patient encounter
initial evaluation - ANSWER-created to establish a plan of care
includes PMH, CMH, current complaints, examination procedures, assessment of
procedures, interventions completed, goal creation, planned interventions,
recommended frequency and duration, and other components
daily treatment note - ANSWER-updated subjective information, newly completed
examination procedures if present, treatment interventions, assessment of those
interventions on pt function
progress note - ANSWER-required to be completed per insurance guidelines
recommended to be completed prior to other medical appointments
assessment related to progress, reassessment of goals, updates to plan of care
