Clinical Center Information Form (Ccif) s1

CLINICAL CENTER INFORMATION FORM

Information for Academic Programs - Part I

I. Information About the Clinical Center

Date (M/D/Y) / 11/15/05
Name of Clinical Center / Northwest Hospital
Address: Street / 1550 N. 115TH
City / Seattle / State / WA / Zip / 98133
Facility Phone / 206-368-1915 / Ext
PT Department Phone / 206-368-1915 / Ext.
Fax Number / 206-368-1924
E-mail address / or
Director of Physical Therapy / Pete Rigby
Center Coordinator of Clinical Education (CCCE) / Cheryl Reinhart
Person completing questionnaire / Cheryl Reinhart

Complete the following table(s) if there are multiple sites that are part of the same health care system or practice. Copy this table before entering information if you need more space.

Name of Clinical Center / Northwest Hospital Outpatient
Address: Street / 10330 Meridan Ave. Nh
City / Seattle / WA / 98133
Facility Phone / 206-368-6032 / Ext
PT Department Phone / 206-368-6032 / Ext.
Fax Number / 206-368-6035
E-mail address / or
Director of Physical Therapy / Pete Rigby
Center Coordinator of Clinical Education (CCCE) / Cheryl Reinhart
Please contact Cheryl for all information at 368-1915
Name of Clinical Center
Address: Street
City / State / Zip
Facility Phone / Ext
PT Department Phone / Ext.
Fax Number
E-mail address
Director of Physical Therapy
Center Coordinator of Clinical Education (CCCE)
Name of Clinical Center
Address: Street
City / State / Zip
Facility Phone / Ext
PT Department Phone / Ext.
Fax Number
E-mail address
Director of Physical Therapy
Center Coordinator of Clinical Education (CCCE)

Clinical Center Name______

Clinical Center Accreditation/Ownership

Yes / No / Date of Last Accreditation/Certification
X / 1. Is your clinical center accredited/ certified? If no, go to #3. / See below
2. If yes, by whom?
X / JCAHO / 4/02 WILL BE COMING SPRING OF 2005
X / CARF / 2/03
X / WA. State—DSHS / 5/03
CORF
Other
3. Who or what type of entity owns your facility/practice? / Hospital

Clinical Center Name______

Place the number 1 next to your facility's primary classification -- noted in bold type. Next, if appropriate, check up to 4 additional bold typed categories that describe other clinical centers associated with your primary classification. Beneath each of the 5 possible bold typed categories, check ( ) the specific learning experiences/settings that best describe that facility.

1 / Acute Care/Hospital Facility / Federal/State/County Health / other
univ. teaching hosp. / VA / 1 / Rehab/Subacute Rehab
pediatric / pediatric develop. ctr. / X / inpatient
X / cardiopulmonary / adult develop. ctr. / X / outpatient
x / urban / other / pediatric
suburban / Home Health Care / X / adult
rural / agency / X / geriatric
other / contract service / SCI
1 / Amubulatory Care/Outpatient / Industrial Rehab. Facility— / TBI
pediatric / Private Practice / other
X / geriatric / pediatric / School/Preschool Program
X / sports PT / geriatric / school system
X / hospital satellite / orthopedic / preschool program
pain center / sports PT / early intervention
X / Other-some industrial rehab—work hardening and conditioning,, lymphedema, vestibular, and balance programs / podiatric / other
ECF/Nursing Home/SNF / corporate practice / Wellness/Prevention Program
medicine for the arts

Clinical Center Name______

Clinical Center Name ___________

5. If your clinical center provides inpatient care, what are the number of:

X / Rehab beds—20---average census 10-12
X / other beds (please specify) / ACUTE—189
total number of beds 219

II. Information About the Physical Therapy Service

6. PT. Service hours / From: (a.m.) / To: (a.m.) / Comments
Monday / 7:30 am / 7:00 pm / OP hours 7:30-7:00
Tuesday / 7:30 am / 7:00 pm /

Hospital hours daily

Wednesday / 7:30 am / 7:00 pm / 8:30-5:00 Sunday through Saturday
Thursday / 7:30 am / 7:00 pm
Friday / 7:30 am / 7:00 pm
Saturday / Closed / Closed
Sunday / Closed / Closed

7. Indicate the number of full-time and part-time budgeted and filled position:

Full time budgeted / Full time filled / Part time budgeted / Part time filled
PTs / 19 / 18 / 6 / 6
PTAs / 3 / 1 / 0 / 0
Aides/Technicians / 5 / 3 / 0 / 0
Administrative personnel / 4 / 4 / 0 / 0
other

8. Estimate an average number of patients per therapist treated per day in the PT department

INPATIENT / OUTPATIENT
10-14 / Individual PT / 12-14 / Individual PT
10-14 / Individual PTA / 0 / Individual PTA
70-75 / Total PT service per day / 160 / Total PT service per day

9. Use the following code to indicate the patient population seen (by age) for inpatient and outpatient services, if appropriate. 1= Frequently 2= Occasionally 3= Rarely 4=Not available

INPATIENT / OUTPATIENT
0 / 1 (neonate) / 0 / 1 (neonate)
0 / 1-4 (preschool) / 0 / 1- 4 (preschool)
3 / 5-12 (school) / 3 / 5-12 (school)
3 / 13-19 (adolescent) / 2 / 13-19 (adolescent)
1 / 20-64 (adult) / 1 / 20-64 (adult)
1 / 65 and older (geriatric) / 1 / 65 and older (geriatric)

Clinical Center Name ___________

10. List all PT and PTA education programs with which you currently affiliate.

University. of Puget Sound / Damen College
University. of Washington / University of Southern California
Eastern Washington University / Green River Comm.College
Pacific University / Tennessee State University
University of Montana / College of Osteopathic Med. Of the Pacific
Creighton University / Rockhurst College
University of the Pacific / East Carolina University
Whatcom Comm. College
Arizona School of Health Sciences

11. Does your clinical facility use (check only one):

X / its own clinical facility contract
the academic institution's contract
whichever contract is most acceptable to both parties
an individualized letter of agreement

12. What criteria do you use to select Clinical Instructors? (check all that apply):

X / years of experience / demonstrated strength in clinical teaching
delegated in job description / X / clinical competence
X / therapist initiative/volunteer / no criteria
career ladder opportunity / other

13. How are Clinical Instructors trained? (check all that apply)

cont. ed. by academic program / professional cont. ed. (eg. chapter, CEU course)
x / cont. ed. by consortia / academic for credit coursework
clinical center inservices / X / no training
1:1 individual training (CCCE:CI) / X / Other—if able attend preceptor training classes

14. Which of the following sources are used to evaluate clinical instructors? (check all that apply)

X / students / Director of Physical Therapy Services
other Clinical Instructors / ACCE/academic program
CCCE / other

15. On pages 4 and 4a please provide information about individual(s) serving as the CCCE(s), and on pages 5 and

5a please provide information about individual(s) serving as the CI(s) at your center.

Clinical Center Name ___________

ABBREVIATED RESUME FOR CENTER COORDINATORS OF CLINICAL EDUCATION

NAME / Cheryl Reinhart / Length of time as the CCCE: / 11 years
DATE / 8/12/03 / Length of time as a CI: / 22yrs
PRESENT POSITION:
(Title, Name of Facility) / Supervisor of In Patient Physical -Therapy / Length of time in practice: / 23
LICENSURE (State/Numbers) / WA 025208 PT00003003 / Certified Specialist:
Other credentials:

SUMMARY OF COLLEGE AND UNIVERSITY EDUCATION (start with most current):

INSTITUTION / PERIOD OF STUDY / MAJOR / DEGREE
FROM / TO
University of Washington / 9/80 / 9/82 / Physical Therapy / BS
University of Colorado / 9/77 / 7/80 / Biology / Transferred

SUMMARY OF PRIMARY EMPLOYMENT (For current and previous four positions since graduation from college; start with most current):

EMPLOYER /
POSITION / PERIOD OF EMPLOYMENT
FROM / TO
Northwest Hospital / PT/Supervisor/CCE / 10/83 / Present
Boswell Memorial Hospital, Sun City AZ / Staff PT / 10/82 / 9/83

Clinical Center Name ___________

CONTINUING PROFESSIONAL PREPARATION RELATED DIRECTLY TO CLINICAL TEACHING RESPONSIBILITIES (eg. academic for credit courses {dates and titles}, Continuing Education {courses and instructors}, Research, Clinical Practice/Expertise, etc. in the last five years):

Innovations in Ther. Movement for Older Adults / Legal Issues in Clinical Education
TQM—Total Quality Management / Recent Advances in the Eval & Tx of the Shoulder
Vestibular Rehabilitation / Recent Advances in the Eval &Tx of the Knee
Prospectivies in Wound Care / Protocol Development for the Successful Wound Care
When the Foot Hits the Ground Everything Changes Basic and Advanced / Geriatric Update
Sports Skills Level I / Restorative Nursing –setting up Restorative Program
Mckenzies’ Back Extension Courses / Being in Balance
Age Related Competencies in Health Care for the Aged / The Therapist’s Role in Programming of Alzheimer’s and Related Dementias
Considerations of the Elderly in Cardiac Rehab / Enhanced Wound Healing through Cellular Facilitation
Pain Management in the Elderly / Documentation & Functional Assessment
New Concepts in Wound Care / Dx & Improving Student Clinical Reasoning
Women’s Health and Stress Management / Preparing for Rehabilitation PPS
PPS for Inpatient Rehab / Dx & Tx of Movement impairment Syndromes of the Lumbopelvic Region
APTA Continuing Ed Series #19—Guide in Action :Patient with THR / APTA Continuing Ed Series # 18—“Typical” Rot Cuff Impingement Syndrome: It’s Not Always Typical
Medicare Documentation Requirements For Rehab Services for Traditional Medicare and PPS Service Delivery / Medicare Documentation for Rehabilitation Services
(preparing for Federal Audit Initiatives for PartA/B Claims)
The Role of the Physciaian after the Diagnosis of Dementia / Promoting Critical Thinking in Clinical Education
GSCCE—1825—Total Hip Replacement / GSCCE-1903—Total Knee Replacement
GSCCE—1826—ACL-Injuries and Treatments / GSCCE—1957—Ethics Problematic Issues and Decision Making
HIV UPDATE—COMPUTER COURSE / Lymphedema Management of the Lower Extremity
Geriatric Exercise—principles and practice for optimal function / Management of Cancer Related Fatigue and Weakness

Clinical Center Name ___________

CLINICAL INSTRUCTOR INFORMATION

Provide the following information on all PTs or PTAs employed in your clinical center who are CIs.

NAME / PT/PTA
School
From Which CI Graduated / Year
of
Graduation / No. of Years of Clinical Practice / No. of Years of Clinical Teaching / Area(s) of Special Clinical Training, Expertise, Practice, Research, and Administration / L = Licensed
E = Eligible
for Licensure
(Use L or E)
Stan Fishman / University of Washington / 1991 / 14 / 13 / Patient Care/Rehab / L
Keith Hill / University of Puget Sound / 1989 / 16 / 15 / Patient Care—OP orthopedics / L
Therese Jensen / University of Montana / 1982 / 23 / 22 / Acute Care/orthopedics / L
Sandra Hayner / Mayo Medical School / 1986 / 19 / 18 / OP orthopedics/Industrial / L
Mark Nelson / University of Puget Sound / 1993 / 12 / 11 / Acute Care/general medicine/Cardiac Rehab / L
Lisa Johnson / University of Puget Sound / 1995 / 10 / 9 / Rehab/wound care / L
Marti McGinley / University of North Dakota / 1983 / 22 / 21 / OP/Sage/orthopedics / L
Michele Sammeth / University of Puget Sound / 1992 / 13 / 12 / OP orthopedics / L
Kimberly Popovic / Bowling Green State University / 2000 / 5 / 4 / OP orthopedics, work conditioning / L
Beth Lyndon-Griffith / University of Puget Sound / 1997 / 8 / 7 / OP orthopedics / L
Pat Mork / North Eastern University / 1973 / 32 / 31 / Acute care/SAGE / L
Joan Nash / University of Manitoba / 1979 / 25 / 2 years with this clinic / Reserve Therapist / L
Carol Chilcoat / University of Washington / 1980 / 24 / Not with this clinic / Reserve Therapist / L
Lee Gordon / University of Pittsburgh / 1989 / 15 / Not with this clinic / TMJ/orthopedic-OP/IP, reserve therapist / L
NAME / PT/PTA
School
From Which Graduated / Year
Graduated / No. of Years of Clinical Practice / No. of Years of Clinical Teaching / Area(s) of Special Clinical Training, Expertise, Practice, Research, and Administration / L = Licensed
E = Eligible
for Licensure
(Use L or E)
Cheryl Reinhart / University of Washington / 1982 / 23 / 22 / Admin/acute care / L
Dave Reinhart / University of Washington / 1982 / 23 / 22 / Admin/OP orthopedics/sports / L
Pete Rigby / Upstate Medical Center / 1981 / 24 / 17 / Admin/Manager of PT / L
Wayne Saito / University of Puget Sound / 1986 / 19 / 18 / Sports/OP orthopedics/orthotics / L
Laura Saito / University of Washington / 1992 / 13 / 12 / OP orthopedics/Vestibular Rehab / L
Dan Shaffer / University of Minnesota / 1976 / 29 / 27 / Rehab / L
Martha Stanton / University of Washington / 1987 / 18 / 17 / OP orthopedics/Industrial Rehab/work conditioning / L
Lynn Thomas / University of Washington / 1980 / 25 / 23 / SAGE/geriatrics / L
Lisa Mosley-Johnson / University of Washington / 1985 / 20 / 16 / OP/SAGE/wound care / L
Carolyn Reid / University of Puget Sound / 1987 / 18 / 17 / OP orthopedics / L
Pamela Sheehan / Green River Community College
(PTA) / 1993 / 12 / 11 / Rehab/acute care / L
Theresa Healy / Reserve Therapist / L
Erin Simons / University of Washington / 2005 / .5 / 0 / General OP and inpatient care / L