Notes on Patient Interviews and Chart Reviews in Skilled Nursing Facilities

PHT5222C - Chart Review and Patient Interview in Skilled Nursing Facility Setting

Overview of Chart Review and Patient Interview Process

• Importance of the medical chart in health care:

  • Crucial source of information before meeting a patient.

  • Provides insights into the patient’s condition, allowing the physical therapist to prepare for the evaluation.

Components of a Thorough Chart Review

• Patient's admitting diagnosis and medical history:

  • Detailed information needed for evaluation.

• Key medical backgrounds to assess:

  • Cardiovascular

  • Integumentary

  • Musculoskeletal

  • Neuromuscular

• Relevant patient history to consider:

  • History of falls, dizziness, or orthostatic issues affecting assistance needed.

  • Recent lab values from hospitalizations.

  • Cognitive status, mental health history, and nutritional condition documented.

  • Any recent surgeries or imposed restrictions critical for safe treatment.

  • Weight-bearing status: Most important for dictating evaluation process.

  • Transfer and ambulation status attained in prior facilities documented.

Patient Interview Following Chart Review

• Purpose of the patient interview:

  • Provides personal connection to the patient.

  • Clarifies discrepancies found in chart.

  • Builds rapport with the patient.

• Considerations for interviewing older adults:

  • Focused on general health status, medications, environmental factors, and functional status/activity level.

General Health Status Assessment

• Patient's self-perception of health status:

  • Use of a health rating scale (0-10) or descriptors (poor, fair, good, excellent) with reasoning.

  • Encouragement for patients to share their detailed health history from their perspective for deeper insights into current function and symptoms (e.g., pain, dizziness).

  • If the patient cannot provide details, inquire with family or caregivers.

• Mental health discussion:

  • Assess if the patient feels down, depressed, or anxious.

• Bowel and bladder incontinence:

  • Sensitive discussion important for older adults due to prevalence.

• Social networks and support:

  • Evaluate family support, social interaction, and societal roles (work, hobbies, community, household).

Polypharmacy in Older Adults

• Definition and implications of polypharmacy:

  • Use of multiple medications due to multiple chronic conditions.

  • Increased risk for adverse drug reactions, such as oversedation and cognitive impairments.

• Importance of verifying medication adherence:

  • Ask patients about their current medications and any recent changes.

  • Identify possible side effects or adverse drug reactions experienced by the patient.

Environmental Factors Assessment

• Influence of environmental factors on patient safety and independence:

  • Evaluation of room setup for mobility barriers or safety hazards (e.g., rugs, low lighting).

  • Gathering information on home layout for anticipated discharges.

• Questions regarding environmental safety:

  • Do you worry about having enough food to eat?

  • Do you have internet access at home?

  • Do you feel safe in your home?

Prior Level of Function and Lifestyle Behavior

• Importance of assessing prior level of function:

  • Helps develop a personalized care plan aligned with patient needs and goals.

• Inquiring about:

  • History of falls.

  • Use of assistive devices.

  • Independence before admission.

• Physical activity and lifestyle behaviors:

  • Recognition that many older adults remain active.

  • Collaborate with the patient to establish individualized goals supporting recovery.

Conclusion

• Collaboration with patients, family, and staff essential for effective chart reviews and interviews.

• Utilization of motivational interviewing techniques to build rapport and gather extensive information.

• Comprehensive understanding of patient needs developed through chart reviews and thorough interviews aids in formulating effective care plans.