Intro Clin Manual v2

8/12/2019 Intro Clin Manual v2

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PART I:

INTRODUCTION TO THE CLINICALSETTING


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I. Physical Therapists and hat They D!(APTAs Guide to Physical Therapist Practice)A. Ed"cati!n and #"ali$icati!ns

%. Physical Therapist Is required to have the following:

a. Pr!$essi!nally ed"cated at the c!lle&e !r "ni'ersity le'el in physicaltherapy c"rric"la appr!'ed (y the appr!priate accreditati!n (!dy

(. Licensed in the state !r states in )hich they practice*. Clinical Specialist

Is a physical therapist that has advanced clinical practice competency with acertificate awarded by the specialty-regulating body of the professional association in any of thefollowing specialty areas:

a. Cardi!'asc"lar and P"l+!nary Physical Therapy(. Clinical Electr!physi!l!&yc. Geriatric Physical Therapyd. Ne"r!l!&ic Physical Therapye. Orth!pedic Physical Therapy$. Pediatric Physical Therapy&. Sp!rts Physical Therapy

,. Practice Settin&sPhysical therapists practice in a broad range of inpatient, outpatient, andcommunity-based settings, including the following:%. H!spitals -critical care intensi'e care ac"te care and s"(/ac"te care0*. O"tpatient clinics !r !$$ices1. Reha(ilitati!n $acilities2. S3illed n"rsin& e4tended care !r s"(/ac"te $acilities5. H!+es6. Ed"cati!n !r research centers7. Sch!!ls and play&r!"nds -presch!!l pri+ary and sec!ndary0

8. H!spices9. C!rp!rate !r ind"strial health centers% . Ind"strial )!r3place !r !ther !cc"pati!nal en'ir!n+ents%%. Athletic $acilities -c!lle&iate a+ate"r and pr!$essi!nal0%*. ;itness centers and sp!rts trainin& $acilities

C. Patients and Clients%. Patients

Individuals who are the recipients of physical therapy examination, evaluation,diagnosis, prognosis, and intervention and who have a disease, disorder, condition, impairment,functional limitation, or disability

*. Clients Individuals or organizations (e g businesses, school systems, athletic teams! who

engage the services of a physical therapist and who can benefit from the physical therapist"sconsultation, interventions, professional advice, prevention services, or services promotinghealth, wellness and fitness

#enerally accepted elements of patient$client management typically apply to bothpatients and clients

D. Sc!pe !$ PracticePhysical %herapy

%he care and services provided by or under the direction and supervision of aphysical therapist

Physical %herapists (P%s! %he only professionals who provide physical therapy

%. Pr!'ide ser'ices t! patients )oss or abnormality of anatomical, physiological, mental, or psychologicalfunction

(. ;"ncti!nal Li+itati!n


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> *estriction of the ability to perform, at the level of the whole person, a physicalaction, tas+ or activity in an efficient, typically expected, or competent manner

c. Disa(ility> Inability to perform or a limitation in the performance of actions, tas+s, and

activities usually expected in specific social roles that are customary for theindividual or expected for the person"s status or role in a specific socio-culturalcontext and physical environment

*. Interact and practice in c!lla(!rati!n )ith a 'ariety !$ pr!$essi!nals ollaboration may be with any of the following:

a. Physicians(. Dentistsc. N"rsesd. Ed"cat!rse. S!cial )!r3ers$. Occ"pati!nal therapists&. Speech/lan&"a&e path!l!&istsh. A"di!l!&istsi. Any !ther pers!nnel in'!l'ed )ith the patient


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Primary care can encompass myriad needs that go well beyond the capabilities andcompetencies of individual caregivers and that require the involvement and interaction of variedpractitioners

Primary care is not limited to the .first contact" or point of entry into the health caresystem

%he primary care program is a comprehensive one%. Ac"te +"sc"l!s3eletal and ne"r!+"sc"lar c!nditi!ns

%riage and initial examination are appropriate physical therapist responsibilities %he primary care team may function more efficiently when it includes physical

therapists, who can recognize musculos+eletal and neuromuscular disorders, performexaminations and evaluations, establish a diagnosis and prognosis, and intervene without delay

Physical therapy intervention may result not only in more efficient and effectivepatient care but also in more appropriate utilization of other members of the primary care team

0ith physical therapists functioning in a primary care role and delivering earlyintervention for wor+-related musculos+eletal in uries, time and productivity loss due to in uriesmay be dramatically reduced

1xample of primary care intervention which physical therapists may engage in apatient$client with low bac+ pain:

a. I++ediate pain red"cti!n thr!"&h pr!&ra+s $!r pain +!di$icati!nstren&thenin& $le4i(ility and p!st"ral ali&n+ent

(. Instr"cti!n in ADLc. !r3 +!di$icati!n

*. Certain chr!nic c!nditi!ns Physical therapists should be recognized as the principal providers of care within the

collaborative primary care team Physical therapists are well prepared to coordinate care related to loss of physical

function as a result of musculos+eletal, neuromuscular, cardiovascular$pulmonary, or integumentary disorders

2sually through community-based agencies and school systems1. Ind"strial and )!r3place settin&s

Physical therapists manage the occupational health services provided to employeesand help prevent in ury by designing or redesigning the wor+ environment focusing on both theindividual and the environment to ensure comprehensive and appropriate intervention

;. R!les in Sec!ndary and Tertiary Care%. Sec!ndary care settin&s

Patients with musculos+eletal, neuromuscular, cardiovascular$pulmonary, or integumentary disorders may be treated initially by another practitioner and then referred tophysical therapists for secondary care in a wide range of settings, including acute care andrehabilitation hospitals, outpatient clinics, home health, and school systems

*. Tertiary care settin&s

Physical therapists provide tertiary care in highly specialized, complex, andtechnology-based settings (e g heart and lung transplant units, burn units! or in response toother health care practitioners" requests for consultation and specialized services (e g for patients with spinal cord lesions or closed-head trauma!

G. R!les in Pre'enti!n and in the Pr!+!ti!n !$ Health ellness and ;itnessPhysical therapists are involved in:

Prevention Promoting health, wellness, and fitness Performing screening activities

%hese initiatives decrease costs by helping patients$clients: &chieve and restore optimal functional capacity inimize impairments, functional limitations, and disabilities related to congenital andacquired conditions aintain health (thereby preventing further deterioration or future illness! and reate appropriate environmental adaptations to enhance independent function

%. Pre'enti!n %hree types of prevention in which physical therapists are involved:

a. Pri+ary pre'enti!n> Preventing a target condition in a susceptible or potentially susceptible


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population through such specific measures as general health promotion efforts(. Sec!ndary Pre'enti!n

> 'ecreasing duration of illness, severity of disease, and number of sequelaethrough early diagnosis and prompt prevention

c. Tertiary Pre'enti!n> )imiting the degree of disability and promoting rehabilitation and restoration of

function in patients with chronic and irreversible diseases*. Pre'enti!n screenin&

Physical therapists conduct screenings to determine the need for:a. Pri+ary sec!ndary !r tertiary pre'enti!n ser'ices(. ;!r $"rther e4a+inati!n inter'enti!n !r c!ns"ltati!n (y a physical

therapist !r c. Re$erral t! an!ther practiti!ner

andidates for screening generally are not patients$clients currently receivingphysical therapy services

3creening is based on a problem-focused, systematic collection and analysis of data 1xamples of prevention screening activities in which physical therapists may engage:

a. Identi$icati!n !$ li$estyle $act!rs -e.&. a+!"nt !$ e4ercise stress )ei&ht0that +ay lead t! increased ris3 $!r seri!"s health pr!(le+s(. Identi$icati!n !$ children )h! +ay need an e4a+inati!n $!r idi!pathic

sc!li!sisc. Identi$icati!n !$ elderly indi'id"als in a c!++"nity centre !r n"rsin& h!+e

)h! are at hi&h ris3 $!r $allsd. Identi$icati!n !$ ris3 $act!rs $!r ne"r!+"sc"l!s3eletal in="ries in the

)!r3placee. Pre/per$!r+ance testin& !$ indi'id"als )h! are acti'e in sp!rts

1. Pre'enti!n acti'ities and health )ellness and $itness pr!+!ti!n acti'ities 1xamples of prevention activities and health, wellness, and fitness promotion

activities in which physical therapists may engage:

a. ,ac3 sch!!ls )!r3place redesi&n stren&thenin& stretchin& andend"rance e4ercise pr!&ra+s? p!st"ral trainin& t! pre'ent and +ana&e l!)(ac3 pain

(. Er&!n!+ic redesi&n? stren&thenin& stretchin& and end"rance e4ercisepr!&ra+s? p!st"ral trainin& t! pre'ent =!(/related disa(ilities incl"din&tra"+a and repetiti'e stress in="ries

c. E4ercise pr!&ra+s incl"din& )ei&ht (earin& and )ei&ht trainin& t!increase (!ne +ass and (!ne density -especially in !lder ad"lts )ith!ste!p!r!sis0

d. E4ercise pr!&ra+s &ait trainin& and (alance and c!!rdinati!n acti'ities t!red"ce the ris3 !$ $alls @ and the ris3 !$ $ract"res $r!+ $alls @ in !lder ad"lts

e. e4ercise pr!&ra+s and instr"cti!n in ADL -sel$/care c!++"nicati!n and

+!(ility s3ills re>"ired $!r independence in daily li'in&0 and IADL -acti'itiesthat are i+p!rtant c!+p!nents !$ +aintainin& independent li'in& s"ch assh!ppin& and c!!3in&0 t! decrease "tili ati!n !$ health care ser'ices andenhance $"ncti!n in patients )ith cardi!'asc"lar


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practitioner, or an organization to recommend physical therapy services that areneeded or to evaluate the quality of physical therapy services being provided

> 2sually does not involve actual intervention lient-related consultation

> 3ervice provided by a physical therapist at the request of an individual, business,school, government agency, or other organization

1xamples of consultation activities in which physical therapists may engage:a. Ad'isin& a re$errin& practiti!ner a(!"t the indicati!ns $!r inter'enti!n(. Ad'isin& e+pl!yers a(!"t the re>"ire+ents !$ the Ba&na Carta $!r

Disa(led Pers!nsc. C!nd"ctin& a pr!&ra+ t! deter+ine the s"ita(ility !$ e+pl!yees $!r

speci$ic =!( assi&n+entsd. De'el!pin& pr!&ra+s that e'al"ate the e$$ecti'eness !$ an inter'enti!n

plan in red"cin& )!r3/related in="riese. Ed"catin& !ther health care practiti!ners -e.&. in in="ry pre'enti!n0$. E4a+inin& sch!!l en'ir!n+ents and rec!++endin& chan&es t! i+pr!'e

accessi(ility $!r st"dents )ith disa(ilities&. Instr"ctin& e+pl!yers a(!"t =!( pre/place+ent in acc!rdance )ith

pr!'isi!ns !$ the Ba&na Carta $!r Disa(led Pers!nsh. Participatin& at the l!cal re&i!nal and nati!nal le'els in p!licy+a3in& $!r

physical therapy ser'icesi. Per$!r+in& en'ir!n+ental assess+ents t! +ini+i e the ris3 $!r $alls

=. Pr!'idin& peer re'ie) and "tili ati!n re'ie) ser'ices3. Resp!ndin& t! a re>"est $!r a sec!nd !pini!nl. Ser'in& as an e4pert )itness in le&al pr!ceedin&s+. !r3in& )ith e+pl!yees la(!r "ni!ns and &!'ern+ent a&encies t!

de'el!p in="ry red"cti!n and sa$ety pr!&ra+s*. Ed"cati!n

%he process of imparting information or s+ills and instructing by precept, example,and experience so that individuals acquire +nowledge, master s+ills, or develop competence

In addition to instructing patients$clients as an element of intervention, physicaltherapists may engage in education activities such as:

a. Plannin& and c!nd"ctin& acade+ic ed"cati!n clinical ed"cati!n andc!ntin"in& ed"cati!n pr!&ra+s $!r physical therapists !ther pr!'idersand st"dents

(. Plannin& and c!nd"ctin& pr!&ra+s $!r l!cal re&i!nal and nati!nala&encies

c. Plannin& and c!nd"ctin& pr!&ra+s $!r the p"(lic t! increase a)areness !$ iss"es in )hich physical therapists ha'e e4pertise

1. Critical In>"iry %he process of applying the principles of scientific methods to read and interpret

professional literature4 participate in, plan, and conduct research4 evaluate outcomes data4 andassess new concepts and technologies 1xamples of critical inquiry activities in which physical therapists may engage:

a. Analy in& and applyin& research $indin&s t! physical therapy practice anded"cati!n

(. Disse+inatin& the res"lts !$ researchc. E'al"atin& the e$$icacy and e$$ecti'eness !$ (!th ne) and esta(lished

inter'enti!ns and techn!l!&iesd. Participatin& in plannin& and c!nd"ctin& clinical (asic !r applied

research2. Ad+inistrati!n

%he s+illed process of planning, directing, organizing, and managing human,

technical, environmental, and financial resources effectively and efficiently Includes the management, by individual physical therapists, of resources for patient$client management and for organizational operations

1xamples of administration activities in which physical therapists may engage:a. Ens"rin& $iscally s!"nd rei+("rse+ent $!r ser'ices rendered(. ,"d&etin& $!r physical therapy ser'icesc. Bana&in& sta$$ res!"rces incl"din& the ac>"isiti!n and de'el!p+ent !$

clinical e4pertise and leadership a(ilities


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d. B!nit!rin& >"ality !$ care and clinical pr!d"cti'itye. Ne&!tiatin& and +ana&in& c!ntracts$. S"per'isin& assisti'e pers!nnel and !ther assisti'e pers!nnel

I. The Physical Therapy Ser'ice: Directi!n and S"per'isi!n !$ Pers!nnel'irection and supervision are essential to the provision of high-quality physicaltherapy%he degree of direction and supervision necessary for ensuring high-qualityphysical therapy depends on many factors, including:

1ducation, experience, and responsibilities of the parties involved 5rganizational structure in which the physical therapy is provided &pplicable state law

In any case, supervision should be readily available to the individual beingsupervised%. Direct!r !$ the Physical Therapist Ser'ice

& physical therapist who has demonstrated qualifications based on clinical educationand experience in the field of physical therapy and who has accepted the inherentresponsibilities of the role

*esponsibilities of the director of the physical therapy service:a. Esta(lish &"idelines and pr!ced"res that )ill delineate the $"ncti!ns and

resp!nsi(ilities !$ all le'els !$ physical therapy pers!nnel in the ser'iceand the s"per'is!ry relati!nships inherent t! the $"ncti!ns !$ the ser'iceand the !r&ani ati!n

(. Ens"re that the !(=ecti'es !$ the ser'ice are e$$iciently and e$$ecti'elyachie'ed )ithin the $ra+e)!r3 !$ the stated p"rp!se !$ the !r&ani ati!nand in acc!rdance )ith sa$e physical therapist practice

c. Interpret ad+inistrati'e p!liciesd. Act as liais!n (et)een line sta$$ and ad+inistrati!ne. ;!ster the pr!$essi!nal &r!)th !$ the sta$$

>

0ritten practice and performance criteria should be available for all levels of physical therapy personnel in a physical therapy service> *egularly scheduled performance appraisals for all levels of physical therapy

personnel in a physical therapy service should be conducted by the director of the physical therapy service based on applicable standards of practice andperformance criteria

> *esponsibilities should be commensurate with the qualifications 6 includingexperience, education, and training 6 of the individuals to whom theresponsibilities are assigned

&lso has responsibilities borne solely by physical therapists (shown below!*. Physical Therapist

0hen the physical therapist directs assistive personnel to perform specific

components of physical therapy interventions, that physical therapist remains responsible for supervision of the plan of care *egardless of the setting in which the service is given, the following responsibilities

must be borne solely by a physical therapist:a. Interpretati!n !$ re$errals )hen a'aila(le(. Initial e4a+inati!n e'al"ati!n dia&n!sis and pr!&n!sisc. De'el!p+ent !r +!di$icati!n !$ a plan !$ care that is (ased !n the initial

e4a+inati!n !r the re/e4a+inati!n and that incl"des physical therapyanticipated &!als and e4pected !"tc!+es

d. Deter+inati!n !$:> 0hen the expertise and decision-ma+ing capability of the physical therapist

requires the physical therapist to personally render physical therapy interventions

and> 0hen it may be appropriate to utilize the physical therapist assistant- 7a physical therapist determines the most appropriate utilization of the physical therapist assistant

that will ensure the delivery of service that is safe, effective, and efficiente. Pr!'isi!n !$ physical therapy inter'enti!ns$. Re/e4a+inati!n !$ the patient


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s"++ary %he only certified paraprofessionals who assist in the provision of physicaltherapy interventions under the direction and supervision of the physical therapist

(. Physical Therapy Aides -PT Aides0> Persons trained under the direction of a physical therapist who perform

designated and supervised routine tas+s related to physical therapy> 8either licensed nor certified> #enerally trained on the ob

2. Other Assisti'e Pers!nnel Persons licensed or certified in another discipline (e g massage therapists, exercise

physiologists, athletic trainers! but who are employees in a physical therapy service under thesupervision of a physical therapist

onsidered and represented as P% &ides if used within the physical therapy service If such persons are providing consultative services, then they are not represented or

billed under physical therapy service but under their specific service disciplines5. S"pp!rt Pers!nnel

8ot involved directly in patient care anagement, clerical or maintenance wor+ers


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II. Pre$erred Practice Patterns in Physical Therapy(APTAs Guide to Physical Therapist Practice)A. Intr!d"cti!n

&P%&"s #uide to Physical %herapist Practice &lso +nown as the #uide

&P%& developed the #uide as a resource not only for physical therapist clinicians,educators, researchers, and students, but for health care policy ma+ers, administrators,managed care providers, third-party payers, and other professionals

%he #uide serves the following purposes:a. T! descri(e physical therapist practice in &eneral "sin& the Disa(le+ent

B!del as the (asis(. T! descri(e the r!les !$ physical therapists in pri+ary sec!ndary and

tertiary care? in pre'enti!n? and in the pr!+!ti!n !$ health )ellness and$itness

c. T! descri(e the settin&s in )hich physical therapists practiced. T! standardi e ter+in!l!&y "sed in and related t! physical therapist

practice

e. T! delineate the tests and +eas"res and the inter'enti!ns that are "sed inphysical therapist practice$. T! delineate pre$erred practice patterns that )ill help physical therapists:

i. I+pr!'e >"ality !$ careii. Enhance the p!siti'e !"tc!+es !$ physical therapy ser'icesiii. Enhance patient


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ii.( The c!++"nicati!n a(ility a$$ect c!&niti!n lan&"a&e and learnin& style!$ the patient &re clinical udgments of the physical therapist that are based on the data

gathered from the examination that are synthesized to establish the diagnosis,

prognosis, and plan of carec. Dia&n!sis> 'iagnostic labels

- ay be used to describe multiple dimensions of the patient$client, ranging from the most basiccellular level to the highest level of functioning 6 as a person in society

i. Typical physician dia&n!stic la(els- Identification of a disease, disorder, or condition at the level of the cell, tissue, organ, or system

ii. Physical therapist dia&n!stic la(els- Identification of the impact of a condition on function at the level of the system (especially the

movement system! and at the level of the whole persond. Pr!&n!sis -incl"din& the Plan !$ Care0

i. Pr!&n!sis- %he determination of the predicted optimal level of improvement in function and the amount of

time needed to reach that level- ay also include a prediction of levels of improvement that may be reached at various intervalsduring the course of therapy

ii. Plan !$ Care- onsists of statements that specify the anticipated goals and expected outcomes, predicted level

of optimal improvement, specific interventions to be used, and proposed duration and frequency of theinterventions that are required to reach the anticipated goals and expected outcomes

- %herefore describes:ii.a Speci$ic patient


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ay be indicated more than once during a single episode of care ay also be performed over the course of a disease, disorder, or condition, which for

some patients$clients may be over the life span Indications for re-examination:

a. Ne) clinical $indin&s

(. ;ail"re t! resp!nd t! physical therapy inter'enti!ns1. Gl!(al O"tc!+es %hroughout the entire episode of care, the physical therapist determines the

anticipated goals and expected outcomes for each intervention 9eginning with the history, the physical therapist identifies:

a. Patient onsists of all physical therapy services that are:i. Pr!'ided (y a physical therapistii. Pr!'ided in an "n(r!3en se>"ence andiii. Related t! the physical therapy inter'enti!ns $!r a &i'en c!nditi!n !r pr!(le+

related t! a re>"est $r!+ the patient


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c. Epis!de !$ Physical Therapy Pre'enti!n> & series of occasional clinical, educational, and administrative services related to

prevention, to the promotion of health, wellness, and fitness, and to thepreservation of optimal function

> 8o defined number or identified range of number of visits is be established for this type of episode

5. Criteria $!r Ter+inati!n !$ Physical Therapy Ser'icesa. Dischar&e

> %he process of ending physical therapy services that have been provided duringa single episode of care, when the anticipated goals have been achieved

> 'oes not occur with a transfer that is when the patient is moved from one site toanother site within the same setting or across settings during a single episode of care

> %here may be facility-specific or payer-specific requirements for documentationregarding the conclusion of physical therapy services as the patient movesbetween sites or across settings during the episode of care

> 5ccurs based on the physical therapist"s analysis of the achievement of anticipated goals and expected outcomes

> /or patients$clients who require multiple episodes of care, periodic follow-up isneeded over the life span to ensure safety and effective adaptation followingchanges in physical status, caregivers, environment, or tas+ demands

> In consultation with appropriate individuals, and in consideration of theanticipated goals and expected outcomes, the physical therapist plans for discharge and provides for appropriate follow-up or referral

(. Disc!ntin"ati!n> %he process of ending physical therapy services that have been provided during

a single episode of care, when:i. The patient


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III. E'idence/,ased Practice and Physical Therapy(Ramona Hicks, PhD, PT and Jeff oppersmith, !", PT)( http#$$%%%&herts&ac&uk$lis$su' ects$health$e'm&htm

)A. hat is E'idence/,ased Practice

'avid 3ac+ett originally proposed it for medicine in the early =>>?s 3ince then,over =,??? articles on this topic have been published in medical ournalsIt is defined as:

@%he udicious use of the best available evidence together with clinical expertise toevaluate, select and implement therapy for individual patientsA (3ac+ett et al =>>B!

Primarily, 19P was developed to clarify doubt on clinical diagnosis, prognosis or managementImportant points on the =>>B definition are:%. "dici!"s

Implies being careful and well-considered*. ,est a'aila(le e'idence

1mbodies the most rigorous clinically relevant research across the spectrum of science from @bench to bedsideA

1. Clinical e4pertise Includes the clinician"s s+ills and past experience in identifying the patient"s health

state, ma+ing diagnoses and the individual ris+s and benefits of possible interventions2. Indi'id"al patients -patient pre$erences0

%his ta+es into account each patient"s unique values, preferences and expectations%hus, it is not solely driven by research studies, but also values clinical expertiseand the wishes of the patient and family when determining optimal interventions/urthermore, this definition ac+nowledges that not all research evidence is equal,and that some research studies should be given greater consideration thanothers when evaluating therapeutic regimens%he philosophy of 19 is also relevant to other health care fields, includingphysical therapy, and in order to be more inclusive, is now often referred to asevidence-based practice (19P!19P has generally, although not universally, been endorsed by health careprofessionals for two ma or reasons /irst, there has been an explosion ininformation, with a ten-fold increase in professional ournals between =>


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> P 0hat individual or patient populations do I have in mind- People with post-polio syndrome

> I 0hat type of exercises am I considering- 3trength training

> Gow does my intervention compare to the effects of another intervention0hat is that other intervention

- *elaxation exercises> 5 0hat are the goals of the exercise intervention

- Increased daily activity level Putting this all together results in a more refined question H/or clients with post-polio

syndrome, is strength training better than relaxation exercises for increasing levels of dailyphysical activity H

*. E$$iciently $ind the (est e'idence. %his step is often easier said than done, but all things considered, the Internet has

greatly increased the ease with which many clinicians can access and rapidly sort currentinformation 5f the numerous databases available for information, a few are particularly relevantto physical therapy

1. Critically appraise the e'idence. 3urprisingly, there are only three critical questions that you need to as+ to appraise

most clinical studies, which are:a. Is the st"dy 'alid(. Are the $indin&s clinically i+p!rtantc. D! the $indin&s apply t! +y client

Gowever, answering each of these three questions requires a systematic analysisIndeed, a series of factors needs to be considered when appraising the validity, such as:

a. as the st"dy retr!specti'e !r pr!specti'e(. as it rand!+i edc. Did it "se h"+an !r ani+al s"(=ects

'epending upon the answers to these and other questions, the validity of theevidence, or in other words, how close it is to the truth, is ran+ed %o appraise the clinicalimportance of the evidence one needs to consider the magnitude of the effect of theintervention, as well as the probability of the effect generalizing to whole patient populations %oappraise the applicability of the findings, you must compare your client to the sub ects used inthe study, consider the feasibility and ris+s and benefits of the intervention, and also determine if it is in line with the client"s preferences

astery of step C is available on the web at http:$$cebm r; ox ac u+ andhttp:$$www fhs mcmaster ca$rehab$ebp$

2. Applyin& critically appraised e'idence t! clinical practice. 5f all the steps, this is the one that may be the most difficult 8umerous challenges face health care providers interested in changing their clinical

practice based on 19P %hese challenges include, but are not limited to:

a. A lac3 !$ c!ntr!l !'er their )!r3l!ad(. C!+petin& pri!ritiesc. Li+ited access t! the Internet and

%o overcome these obstacles, it helps to start small /orm a lunchtime ournal club tocritically appraise relevant clinical studies 9e a Hclinician-scientistH by using valid and reliabletests and measures to acquire baseline measurements and evaluate outcomes of your clients3earch for a topic of interest on Pub ed or another database 9e part of the &P%& Goo+ed on1vidence Initiative %hese are ust a few of many possible ways to begin to integrate 19P intoclinical practice

5. E'al"ate the e$$ects !$ E,P !n clinical !"tc!+es. 0hether incorporating 19P into physical therapy practice will increase the li+elihoodthat all patients$clients receive interventions that are effective is un+nown %he essence of 19Pis an argument for critical appraisal of therapeutic interventions 0isely, the people whodeveloped 19P extended this requirement not only to clinical interventions, but also to 19Pitself /uture studies are needed to determine if there is a correlation between the integration of 19P into clinical practice and improvements in outcomes

In conclusion, 19P is a five-step process that aims to improve health care
http://cebm.jr2.ox.ac.uk/http://www.fhs.mcmaster.ca/rehab/ebp/http://cebm.jr2.ox.ac.uk/http://www.fhs.mcmaster.ca/rehab/ebp/


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outcomes by balancing findings from research with clinical experience andpatient$family preferences

C. E'idence/,ased Practice Res!"rces%. e(sites

a. APTA s H!!3ed !n E'idence Initiati'e> https:$$www apta org$hoo+edonevidence$index cfm> %he contents of this site provide learning tools to foster evidence based practice

in physical therapy(. Centre $!r E'idence/,ased Bedicine at O4$!rd Uni'ersity L!nd!n En&land

> http:$$cebm r; ox ac u+$> & lot of the original wor+ and dissemination of information about 19P can from

this group of physicians and scientists It is an excellent site and contains currentreferences on the theory and methodology of 19P, as well as a substantialannotated list of Internet sites It also contains tutorials and practical guidelinesfor incorporating 19P into clinical practice

c. Occ"pati!nal Therapy E'idence/,ased Practice Research Gr!"p> http:$$www fhs mcmaster ca$rehab$ebp$> %his site has great lin+s to guidelines and forms for critical analysis of research

d. Nettin& the E'idence: Lin3s t! e'idence/(ased practice s!"rces> http:$$www shef ac u+$ scharr$ir$core html> %his site has a comprehensive list of annotated evidence-based research

Internet sitese. E'idence ,ased Health Care / Latest Articles

> http:$$www ebmny org$pubs html> %his site may offer some advantages over the entre for 1vidence-9ased

edicine at 5xford 2niversity for members of P%0& because it is located in the23&

$. The Dart+!"th Atlas !$ Health> http:$$www dartmouthatlas org$default php> %his is an interesting site and reinforces the need for systematic analysis of the

ris+s and benefits of various medical and health care interventions*. e( data(ases

a. Uni'ersity !$ ashin&t!n Li(rary Gate)ay> http:$$www lib washington edu$> lic+ on /ind It to get to databases

(. P"(BED: BEDLINE !$ the Nati!nal Li(rary !$ Bedicine: $ree t! the p"(lic> http:$$www ncbi nlm nih gov$Pub ed> %he largest database of publications on medicine and health care /ree and

available to the public Includes a tutorial (which is highly recommended! on howto use it to optimize your searches

c. CINAHL Citati!ns in N"rsin& and Allied Health Literat"re> http:$$www cinahl com$index html> %his database often includes publications not on Pub ed, but with high

relevance to physical therapy *equires a site license, which can be for anindividual or group

d. C!chrane Li(rary> http:$$www cochranelibrary com$clibhome$clib htm> %he ochrane )ibrary is an electronic publication that contains systematic

overviews of the effects of health care Provides free access to abstracts %heochrane )ibrary is an invaluable source of review articles on important topics,

however often they are more closely lin+ed to medicine, rather than to physicaltherapy In the future, the &P%& Goo+ed on 1vidence Initiative may provide asimilar source of information, but with a focus on topics directed toward physicaltherapy

e. PEDr!: The Physi!therapy E'idence Data(ase !$ the Centre $!r E'idence/,ased Physi!therapy Sch!!l !$ Physi!therapy Uni'ersity !$ SydneyA"stralia.

> http:$$ptwww cchs usyd edu au$ 19P$index htm> http:$$ptwww cchs usyd edu au$pedro$> 'esigned for physical therapists, access to bibliographic data, abstracts, and

systematic reviews of the literature Includes a tutorial$. Reha(Trials.!r&
https://www.apta.org/hookedonevidence/index.cfmhttp://cebm.r2.ox.ac.uk/http://www.fhs.mcmaster.ca/rehab/ebp/http://www.shef.ac.uk/~scharr/ir/core.htmlhttp://www.ebmny.org/pubs.htmlhttp://www.dartmouthatlas.org/default.phphttp://www.lib.washington.edu/http://www.ncbi.nlm.nih.gov/PubMedhttp://www.cinahl.com/index.htmlhttp://www.cochranelibrary.com/clibhome/clib.htmhttp://ptwww.cchs.usyd.edu.au/CEBP/index.htmhttp://ptwww.cchs.usyd.edu.au/pedro/https://www.apta.org/hookedonevidence/index.cfmhttp://cebm.r2.ox.ac.uk/http://www.fhs.mcmaster.ca/rehab/ebp/http://www.shef.ac.uk/~scharr/ir/core.htmlhttp://www.ebmny.org/pubs.htmlhttp://www.dartmouthatlas.org/default.phphttp://www.lib.washington.edu/http://www.ncbi.nlm.nih.gov/PubMedhttp://www.cinahl.com/index.htmlhttp://www.cochranelibrary.com/clibhome/clib.htmhttp://ptwww.cchs.usyd.edu.au/CEBP/index.htmhttp://ptwww.cchs.usyd.edu.au/pedro/


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> http:$$www rehabtrials org&. ClinicalTrials.&!'

> http:$$clinicaltrials gov$1. Print S!"rces

a. Garrard . Health Sciences literat"re re'ie) +ade easy: The +atri4+eth!d. Gaithers("r& BD: Aspen? %999.

(. Harris SR. H!) sh!"ld treat+ents (e criti>"ed $!r scienti$ic +eritPhysical Therapy 76:%75/%8%? %996.

c. La) B. E'idence/(ased reha(ilitati!n: A &"ide t! practice. Th!r!$are N:Slac3? * *.

d. Sac3ett DL Stra"ss SE Richards!n S R!sen(er& Hayes R,.E'idence/(ased +edicine: h!) t! practice and teach E,B. *nd Ed. Ne)

F!r3: Ch"rchill Li'in&st!ne? * .e. T!nelli B. The phil!s!phical li+its !$ e'idence/(ased +edicine. Acade+ic

Bedicine. 71: %*12/%*2 ? %998.$. Als! see E'idence/,ased Bedicine $!r a list !$ c"rrent and "p/dated

re$erences !n the the!ry and +eth!d!l!&y !$ E,P.
http://www.rehabtrials.org/http://clinicaltrials.gov/http://www.rehabtrials.org/http://clinicaltrials.gov/


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PART II:

PHFSICAL THERAPFDOCUBENTATION


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I . Intr!d"cti!n t! Physical Therapy D!c"+entati!nA. P"rp!ses !$ D!c"+entati!n

&ll healthcare professionals document their findings for several reasons:%. N!tes rec!rd )hat the therapist d!es t! +ana&e the indi'id"al patient s case.

&ll medical records are legal documents

*. D!c"+entati!n is a +eth!d !$ c!++"nicatin& )ith the patient s physician and!ther healthcare pr!$essi!nals incl"din& !ther therapists and therapistassistants.

ommunication through documentation provides consistency between the servicesprovided by various healthcare professionals

1. Third/party payers +a3e decisi!ns a(!"t rei+("rse+ent (ased !n therapyn!tes.

*eimbursement decisions can be greatly influenced by the quality and completenessof documentation

2. ithin the $acility patient charts are re'ie)ed. 'ischarge or further intervention decisions are made based, in part, on the

documentation written by healthcare professionals5. Pr!per d!c"+entati!n helps the therapist t! !r&ani e the th!"&ht pr!cesses

in'!l'ed in patient care. 'ocumentation structures thin+ing for problem solving

6. D!c"+entati!n can (e "sed $!r >"ality ass"rance and i+pr!'e+ent p"rp!ses. ertain criteria are set to indicate whether quality care is occurring

7. D!c"+entati!n can (e "sed $!r research. 'ata from documentation can be gathered and conclusions can be drawn

'ocumentation is an integral part of the patient care process as the assessmentor treatment of the patient

,. Relati!nship !$ D!c"+entati!n t! the Decisi!n/+a3in& Pr!cess'uring an initial session with a patient, the process of assessment and decision-

ma+ing occurs in the following manner:%. The therapist reads the patient s chart -+edical rec!rd0 !r re$erral -i$ either isa'aila(le0.

'ata gathered here are under Identifying 'ata$'emographics*. The therapist then inter'ie)s the patient.

'ata gathered here are under 3ub ective1. ;r!+ the in$!r+ati!n &athered $r!+ the +edical rec!rd and the patient the

therapist plans the !(=ecti'e +eas"re+ents t! (e per$!r+ed. Then the planned+eas"re+ents are c!+pleted.

'ata gathered here are under 5b ective2. The therapist interprets the in$!r+ati!n rec!rded and identi$ies $act!rs that are

n!t )ithin n!r+al li+its $!r pe!ple in the sa+e a&e ran&e as the patient. ;r!+these $act!rs the therapist $!r+"lates a list !$ the patient s pr!(le+sincl"din& $"ncti!nal li+itati!ns i+pair+ents and disa(ilities.

'ata here are placed under &ssessment, specifically Problem )ist5. The therapist and the patient t!&ether esta(lish !"tc!+es that c!rresp!nd t!

the patient s $"ncti!nal li+itati!ns i+pair+ents !r disa(ilities. 'ata here are placed under &ssessment, specifically )ong %erm #oals$/unctional

5utcomes$1xpected 5utcomes6. The therapist and the patient then c!nsider )hat can (e achie'ed )ithin a

sh!rt peri!d !$ ti+e -anticipated &!als0. 'ata here are placed under &ssessment, specifically 3hort %erm #oals$&nticipated

#oals

7. The therapist $!r+"lates i+pressi!ns !$ the patient s pr!(le+s and c!nditi!ns. 'ata here are placed under &ssessment, specifically3ummary$Impression$Prognosis

8. The therapist !"tlines a treat+ent plan t! achie'e the+. 'ata here are placed under Plan$Plan of are$Interventions

C. ritin& in a Bedical Rec!rd%he writing style used in medical records differs from the style most students areaccustomed to using when writing papers, reports, et al


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%. Characteristics !$ G!!d D!c"+entati!n in a Bedical Rec!rd:a. ORGANI ED

> &ll entries in a chart must be arranged in such a way that facilitates use by other health personnel in the same facility

> In an organized chart:i. All entries are in their pr!per l!cati!n.

ii. The sheets are pr!perly arran&ed.iii. The data is rec!rded as a se>"ence !$ e'ents.

> 1ach facility has its own policies on charting and recording, so familiarizeyourself with the policies in every new facility

(. CHRONOLOGICALLF ARRANGED> &ll entries must have a date and time> Gas legal implications> &voids unnecessary duplication of services and unnecessary queries

c. AUTOGRAPHED> &ll entries must have the printed name and signature of the person who

evaluated$treated the patient at the end of the written report$prescriptiond. ;E A,,RE IATIONS

> 2se only internationally accepted abbreviations and use them as infrequently aspossible> Implications if not followed:

ay lead to misinterpretation and confusion5ther users of the chart may not be familiar with the abbreviations used

e. TRUE RECORD O; ACTUAL O,SER ATIONS &ll entries must be those that were actually obtained$elicited> 1ntries must not be copied from other health professionals" documentation but

may be recorded only if therapist repeats the test and confirms the given finding$. PROBPTLF RECORDED

> &ll entries must be recorded immediately after obtaining them or after treatment> If not recorded promptly, other health professionals may have written notes

ahead of your note so chart does not become chronologically arranged&. ,RIE; ,UT COBPLETE RELE ANT AND SENSI,LE

> %ime is valuable but this does not be used as an excuse to shortcut procedures,not to write legibly, use plenty of abbreviations, and$or edit the more importantdata

h. LEGI,LE> 3elf-explanatory

*. ,asic G"idelines in Chartin&chr!n!l!&ically arran&ed rec!rd.

d. Bini+i e "se !$ a((re'iati!ns and "se !nly "ni'ersally accepteda((re'iati!ns.e. Rec!rd !nly in$!r+ati!n that )as act"ally !(ser'ed and

si&nat"re a(!'e the printed na+e.&. D! n!t lea'e spaces (et)een entries t! a'!id ta+perin&.h. Ne'er chan&e an entry +ade (y an!ther health pr!$essi!n n!r ta+per )ith

any !$ the data c!ntained in a chart.i. rite le&i(ly.

=. ,e speci$ic and direct t! the p!int.1. S!+e Speci$ics Re&ardin& ritin& in a Bedical Rec!rd:

Punctuation

a. Hyphen -/0> an be confused with .minus sign" or .negative"> 1xception only if used instead of the word .through"> 1xample: ? - 2sed instead of overusing .states" in the 3ub ective portion to connect related

statements


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> 1xample:- Instead of: 3tates position of comfort for sleep is on J side 3tates pain does not awa+en pt at

night- 91%%1*: 3tates position of comfort for sleep is on J side4 pain does not awa+en pt at night

c. C!l!n -:0> an be used instead of .is"> 1xample:- Instead of: &*5 J shoulder is ? ->?

- 91%%1*: &*5 J shoulder: ? ->? orrecting 1rrors

> 8ever use correction fluidKKK> harting errors should be corrected by drawing a single line through the error,

write .(error!" above the mista+e, date it, and initial it> 1xample:

(error! L P ==$=E$?Csome minM= assist

3igning Nour 8otes> &ll notes should be signed with your legal signature (your last name and legal

first name or initials!> 8o nic+names should be used> Initials should follow your name indicating your status$designation> 1xample:

J PhoenixLason Phoenix, 3P%

*eferring to Nourself > 8otes discuss the patient and not the therapist> If a therapist must ma+e reference to himself$herself, reference should be made

in the third person> 1xample: Pt states therapist should be putting his shoes on for him li+e his

family does at home 3paces, 9lan+s or 1mpty )ines

> 3hould not be left between one entry and another, nor be left within a single entry> ould become areas in which another person could falsify information already

charted 0riting 5rders in a hart

> 0hen a physician gives an order to a therapist, the therapist is responsible for writing it in the chart

> 3tandard format:date$time$order v o physician"s name$therapist"s signature, status$designation

5*date$time$order verbal order by physician"s name$therapist"s signature, status$designation

> 1xample:==-=E-?C$==:


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centers where healthcare professionals see more than ten (=?! patients a day any facilities never use the P5 * 0idespread use of the 35&P note format is one clear contribution 1ach professional field and each facility has its own variation of the 35&P note

format

35&P stands for:> 3 6 3ub ective> 5 6 5b ective> & 6 &ssessment> P 6 Plan

*. ;"ncti!nal O"tc!+es Rec!rdin& &dapted from the traditional 35&P note format 1mphasizes and discusses the patient"s functional status and sets goals and

treatment to improve function only


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. Trends in Physical Therapy D!c"+entati!nA. Bedicare ;!r+s

In the 2nited 3tates, edicare has developed several forms (E??, E?=, E?;! inan attempt to gather consistent data needed to ma+e decisions about whether the patient"s condition and treatment qualifies for edicare coverage

9efore these forms were developed, reviewers for edicare were receiving poor quality patient notes'ata seen in edicare forms are:%. De+!&raphic data*. ,asic +edical data1. Data that sh!"ld already (e c!ntained in a )ell/)ritten SOAP n!te li3e:

a. ;"ncti!nal stat"s pri!r t! treat+ent(. C"rrent $"ncti!nal stat"sc. L!n& ter+ &!alsd. Sh!rt ter+ &!als -listed as +!nthly &!als0e. Treat+ent plan$. "sti$icati!n $!r treat+ent

,. D!c"+entati!n ;!r+s%his type of documentation is used in many clinics 3ome reasons for this are:

'ecreasing the amount of writing by the therapist$assistant Increasing the efficiency of the therapist$assistant in documenting patient care Increasing the consistency of documentation (and thus fulfilling certain quality

assurance or legal$ris+ management requirements! by building certain components into a note,such as whether the patient is given a home program and his$her level of independence inperforming the home program

a+ing the data gathered for outcomes studies more consistent a+ing functional information easier to read by all parties who use the information

/orms are usually individualized to fit the needs of the individual healthcareinstitution and its patient population%. Types !$ D!c"+entati!n ;!r+s

a. ;l!) sheets(. Initial assess+ent < dischar&e n!te $!r+sc. Interi+ < dischar&e n!te $!r+sd. One/'isit/!nly d!c"+entati!n $!r+se. S"pple+ental $!r+s

> %hese forms are to be attached to initial, interim, or discharge forms and oftenhave specialized tests or scales that are only needed with certain types of patients

*. De'el!p+ent !$ D!c"+entati!n ;!r+s 0hen designing a form, a good place to start is by watching clinicians practice

wherein items to be included in the form are those that are commonly assessed by the therapist5ther additions to the forms can be obtained by as+ing staff members to use the forms and givefeedbac+ to those designing the forms

0hen beginning to use a new form, it is important for the therapist $ assistant to givehimself $ herself time to adapt to the use of the form to improve efficiency in the use of the form

%he most efficient use of a form is to complete a form, or at least begin itscompletion, while seeing the patient 3ub ective and ob ective findings may be written directly onthe form, if permissible, to save time

If a form is limited, specifically if an item is missing from the form, the therapist $assistant must find a place to write the missing item if it is relevant to the patient"s function

/orms should also be revised on a regular basis to meet the needs of good clinical

practice 0hen developing a form, the following should be considered:a. D! n!t start $r!+ scratch. Re'ise a $!r+ $r!+ an!ther $acility )ith

per+issi!n "sin& the !ther $acility s $!r+ as the (asis $!r the present$acility s $!r+.

(. A$ter a dra$t 'ersi!n has (een +ade th!se )h! "se and read the $!r+s+"st (e as3ed )hat it is s"pp!sed t! d! $!r all parties in'!l'ed.

c. C!++"nicate )ith all parties in'!l'ed )hen de'el!pin& $!r+s. I$ the $!r+


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is t! (e "se$"l e'ery!ne +"st 3n!) h!) t! "se the $!r+ (!th )ritin& !nthe $!r+ and readin& the $!r+.

d. S"(=ecti'e and !(=ecti'e ite+s c!++!nly assessed (y the sta$$ +"st (eincl"ded.

e. I$ a standard scale test !r de$initi!n !$ +eas"re+ent is "sed (y all sta$$ t!+eas"re !r d!c"+ent a certain characteristic !$ the patient !r a certain$acet !$ patient care a chec3list +ay (e $aster in d!c"+entin& patient care.

$. Chec3lists can sa'e therapist ti+e and add speed in d!c"+entati!n.&. I$ any s!rt !$ chec3lists are "sed in n!te $!r+s try t! +a3e the chec3lists

c!nsistent !r si+ilar $r!+ !ne $!r+ t! an!ther t! sa'e c!n$"si!n and"nnecessary sta$$ re!rientati!n ti+e.

h. ;re>"ently lea'e space $!r 'ery (rie$ c!++ents !r descripti!ns.i. Unless the $!r+ is created )ith a 'ery speci$ic patient p!p"lati!n in +ind

all!) $!r a &eneral assess+ent !$ the patient. =. I$ there are n! standardi ed +eth!ds !$ d!c"+entin& the in$!r+ati!n

deri'ed $r!+ y!"r assess+ent !$ the patient all!) r!!+ $!r )ritin&.3. ;!r+s )ill in$l"ence practice s! +a3e s"re t! incl"de ite+s that are

(elie'ed essential t! practice.l. I$ the sta$$ has (een )ritin& SOAP n!tes transiti!n $!r the sta$$ )ill (e

easier i$ a SOAP $!r+at is $!ll!)ed (eca"se SOAP is a pr!(le+/s!l'in&$!r+at and d!c"+entin& "sin& this $!r+at !n a $!r+ assists the sta$$in&pr!(le+ s!l'in&.

+. ;"ncti!n sh!"ld still (e stated $irst in the s"(=ecti'e and !(=ecti'e p!rti!ns!$ the n!te $!r+ ="st as )hen )ritin& a SOAP n!te.

C. C!+p"teri ed D!c"+entati!n Pr!&ra+somputerized documentation is still in the stages of development 3ome facilities

have a well-developed program that is tailored to the needs of that facility%. Ad'anta&es !$ C!+p"teri ed D!c"+entati!n !'er Paper/(ased

D!c"+entati!n:a. In$!r+ati!n placed in a paper/(ased d!c"+entati!n +ay (e li+ited d"e t!

li+ited space all!)ed $!r in$!r+ati!n in a $!r+ )hile in$!r+ati!n that +ay(e placed in a c!+p"teri ed d!c"+ent is n!t li+ited.

(. C!+p"ters can als! ha'e all !$ the p!ssi(le tests and +eas"re+entsa'aila(le s! the therapist is n!t li+ited (y the tests and +eas"re+entsa'aila(le !n a &i'en $!r+.

*. S!+e ;eat"res That Ha'e ,een De'el!ped !r are In Sta&es !$ De'el!p+entThat ill Ba3e C!+p"ters E'en Easier t! Use in the ;"t"re:a. Data can (e entered (y +a3in& ch!ices and si+ply t!"chin& a styl"s t! the

screen.> %his ma+es data entry more consistent and does not require +eyboard

competence(. Data can (e printed in a 'ariety !$ $!r+ats.

> 3ince computerized documentation programs utilize data in a database form,required data in different forms may be directly placed in corresponding spaces

> It could also allow the therapist to choose certain functional or relevant data tosend to the patient"s physician or other referral source

c. The +edical rec!rd can (e retrie'ed and n!tes )ritten at the patient s(edside.

> 3ome healthcare facilities have computers located in every patient"s room or between every two rooms

> %he therapist may be able to use a noteboo+ computer with him $ her thatcontains and $ or can access the patient"s medical record and rehab informationfor all the patients the therapist treats

d. All d!c"+entati!n can (e c!+pleted at (edside.> 1ven outpatient and home healthcare therapists will be able to have a noteboo+

computer with them and be able to transmit $ receive information via modem or other electronic means

e. Hand)ritin& rec!&niti!n is a $eat"re that )ill (e de'el!ped +!re in the ne4t$e) years.

> %his will enable the therapist to enter extra notes and information as needed$. !ice rec!&niti!n is a $eat"re that )ill als! (e de'el!ped +!re in the ne4t

$e) years.


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> %his could completely change methods of data entry, although some cautionmust be ta+en in the use of voice-activated methodology while at the patient"sbedside

&. Char&in& )ill (e a(le t! (e d!ne (y the therapist i++ediately "p!nc!+pletin& the patient s treat+ent and )hile he < she c!+pletes !ther c!+p"teri ed d!c"+entati!n -and the c!+p"ter +ay re+ind the therapistt! char&e the patient.0

> omputerized charging systems exist in many clinics today oving the chargingto the patient"s bedside, along with all other documentation functions, will greatlyincrease therapist efficiency and relieve the repetition in documentation thatsome therapists experience today

1. Ite+s t! C!nsider hen L!!3in& at C!+p"teri ed D!c"+entati!n Syste+s: It is important to consider the needs of the therapists at their individual practice sites

> & system should be flexible enough to fulfill the needs of the therapist at theindividual practice site4 otherwise, the system is not worthwhile

a. C!+p"teri ed d!c"+entati!n syste+s 'ary in their +!(ility )ei&ht$le4i(ility ease !$ "se speed !$ data entry and speed !$ the hard)are.

> &ll of these factors must be considered when purchasing or developing acomputerized system

(. Trainin& ti+e +"st (e ta3en int! c!nsiderati!n )hen y!" disc"ss the c!st!$ a c!+p"teri ed d!c"+entati!n syste+.

> & system that requires extensive training must also save much time I order to becost effective

c. Techn!l!&y is !nly )!rth)hile i$ it +a3es the therapist s tas3 !$ d!c"+entati!n easier and all!)s hi+ < her t! d! s!+ethin& he < she c!"ldn!t d! )ith!"t the techn!l!&y.

> /or example, the time spent documenting should be decreased, and spellingerrors or obvious errors in the recording of data should be pointed out to thetherapist automatically for the purpose of immediate correction

d. The )illin&ness a'aila(ility and c!st !$ pr!&ra++ers t! c"st!+i e thesyste+ t! the indi'id"al $acility s needs sh!"ld (e in'esti&ated (e$!re+a3in& a c!++it+ent t! a c!+p"teri ed d!c"+entati!n syste+.


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I. O(tainin& and D!c"+entin& S"(=ecti'e C!ntentA. Intr!d"cti!n t! the Inter'ie)in& Pr!cess and Re'ie)in& the Bedical Rec!rd

Interviewing is an important s+ill for the clinician to learn#enerally agreed that D?O of the information needed to clarify the cause of symptoms is contained within the sub ective examination

9egin the interview by determining the patient"s chief complaint ( $ :!2sually is a symptomatic description of the patient (i e , sub ective sensationsreported, such as fatigue, dizziness, night sweats, fever!%he interview, especially in the sub ective data, may also reveal contraindicationsto physical therapy treatment or indications for the +ind of treatment that is moreli+ely to be effective

1xample: & patient examined by a physical therapist last year found that ultrasound was the mosteffective method for providing long-term relief of symptoms

uestioning the patient may also assist the physical therapist in determining thein ury stage

#uides the clinician in providing appropriate treatment in the in ury stage:a. Ac"te in="ry / sy+pt!+atic relie$.(. Chr!nic in="ry / +!re a&&ressi'e treat+ent.c. S"(/ac"te in="ry / c!+(inati!n !$ the a(!'e +eth!ds.

Interviewing the patient and reviewing the patient"s medical record will help thephysical therapist to determine the location and potential significance of anysymptom (including pain!%he interview format provides detailed information regarding the frequency,duration, intensity, length, breadth, depth, and anatomic relation as these relateto the patient"s chief complaint%he physical therapist will later correlate this information with the ob ective

findings of the examination to rule out possible systemic origins of symptoms%he information obtained from the interview guides the physical therapist in either referring the patient to a physician or in treating the patient in a clinic

,. Inter'ie)in& Techni>"es &n organized interview format assists the physical therapist in obtaining acomplete and accurate database2sing the same outline with each patient ensures that all pertinent informationrelated to previous medical history and current medical problem(s! is included

%his information is especially important when correlating the sub ective data withob ective findings from the physical examination

%. Open/ended #"esti!ns uestions that elicit more than a one-word response &dvantage: can prevent a false-positive or false-negative response that otherwise

would be elicited by a closed-ended question 'isadvantage: may allow the patient to control the interview through an organ recital

> 5rgan *ecital 6 a patient provides detailed information regarding &)) previouslyexperienced illnesses and symptoms that may or may not be related to thecurrent problem$

- 1xample:.%he pain in my hip started =; years ago when I was a corpsman in the navy standingon my feet =? hours a day It seems to bother me most when I am havingpremenstrual symptoms, such as food cravings or depression y left leg is longer than my right leg, and my hip hurts when the scars from by bunionectomy ache %his

pain occurs with any changes in the weather I have a bleeding ulcer that bothers me,and the pain +eeps me awa+e at night I dislocated my shoulder ; years ago, but Ican lift weights now without any problems "

1xample:.%ell me why you are here "

*. Cl!sed/ended #"esti!ns *equire only a .yes" or .no" answer 'isadvantages:


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a. Tend t! (e +!re i+pers!nal and +ay set an i+pers!nal t!ne $!r therelati!nship (et)een the patient and the physical therapist.

(. Li+ited (y the restricti'e nat"re !$ the in$!r+ati!n recei'ed s! that thepatient +ay !nly resp!nd t! the cate&!ry in >"esti!n and +ay !+it 'ital("t see+in&ly "nrelated in$!r+ati!n.

c. Bay elicit $alse/p!siti'e !r $alse/ne&ati'e resp!nses that de'el!p $r!+ thepatient s atte+pt t! pleas the health care pr!'ider !r t! c!+ply )ith )hatthe patient (elie'es is the c!rrect resp!nse !r e4pectati!n.

1xample:.'o you have any pain after lying in bed all night "

1. ;"nnel Techni>"e"esti!ns.(. Can esta(lish an e$$ecti'e $!r"+ $!r tr"st (et)een the patient and physical

therapist. 1xample of funnel sequence:

> 9eginning (open-ended! question:.Gow does rest affect the pain or symptoms "

> /ollow-up questions:.&re your symptoms aggravated or relieved by any activities ".If yes, what ".Gow has this affected your daily life at wor+ or at home ".Gow has this problem affected your ability to care for yourself without assistance (e g ,dress, bathe, coo+, drive! "

2. Paraphrasin& Techni>"e %he interviewer repeats information presented by the patient &dvantage: can assist in fostering effective, accurate communication between the

patient and the physical therapist 1xample:

.Nou"ve told me that the pain is relieved by wal+ing around, is that right 0hat other activitiesor treatment brings you relief from your pain or symptoms "

If the therapist cannot paraphrase what the patient has said, or is unclear about themeaning of the patient"s response, clarification is achieved by requesting an example of whatthe patient is tal+ing about

C. Inter'ie)in& T!!ls &re self-assessment forms &re employed to identify problems, to quantify symptoms, and to demonstrate theeffectiveness of treatment%here is no single interviewing tool that can be considered to be the best under all circumstances

ost common interviewing tool employed, especially for pain, is the c#ill Painuestionnaire

D. Identi$yin& Data


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d. It $acilitates c!nd"ct !$ epide+i!l!&ic researches as )ell as $!ll!)/"presearches

*. Typesa. En"+erated:

8ame: arciano, #eorge &ge: ;D y o

&ddress: =? /airlane Qillage, 9rgy #uadalupe, ebu ity3ex: R8ationality: /ilipino

ivil 3tatus: 3ingle5ccupation: 1ncoder *eligion: *oman atholicGandedness: JPhysiatrist: 'r L )asco'ate of 1val: 8ovember =>, ;??C'x: J arpal %unnel 3yndrome

edications: &laxanP% Imp : Impaired grip ;S to J arpal %unnel 3yndrome

5r:

8ame: arciano, #eorge *eligion: *oman atholic &ge: ;D y o Gandedness: J &ddress: =? /airlane Qillage, 9rgy

#uadalupe, ebu ityPhysiatrist: 'r L )asco'ate of 1val: 8ovember =>, ;??C

3ex: R 'x: J arpal %unnel 3yndrome8ationality: /ilipino edications: &laxan

ivil 3tatus: 3ingle P% Imp : Impaired grip ;S to J arpal%unnel 3yndrome5ccupation: 1ncoder

(. Narrati'e:ase of #eorge arciano, a ;D y o R, single, /ilipino, *oman atholic, encoder

currently residing in =? /airlane Qillage, 9rgy #uadalupe, ebu ity who was evaluatedand referred for P% by 'r L )asco 8ovember =>, ;??C with a diagnosis of J arpal%unnel 3yndrome

E. Statin& the Pr!(le+ !r Dia&n!sis2sually is stated in a medical record or referral under the heading 'x :In some facilities, pertinent history or medical information ta+en from the chart isincluded in the Problem or 'iagnosis'x : is included in the Identifying 'ata$'emographics since it is usually obtainedfrom the documentation of other healthcare professionals3ome information to be included in the Problem or 'x :%. Past s"r&eries a$$ectin& the present c!nditi!n


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i. Anythin& rele'ant t! the patient s case !r present c!nditi!n1. The "se !$ Patient

&cceptable to use .Pt " the first time, but not to be repeated with every sentence &ssumed, unless otherwise stated, that the information in 3ub ective came from the

patient2. Or&ani ati!n:

5rganize by topic 3ubcategories or headings may be used to facilitate searching for information

5. ;re>"ently Used er(s in the S"(=ecti'e C!ntent: 3ub ective content frequently contain a verb which indicates that the statement is

sub ective and not ta+en from the charta. States(. Descri(esc. Deniesd. Indicatese. C

6. #"!tin& the Patient er(ati+:

&t times, quoting the patient verbatim is the appropriate method of conveyingsub ective information 3ome reasons for using direct quotes from the patient or significant other:

a. T! ill"strate c!n$"si!n !r l!ss !$ +e+!ry(. T! ill"strate denialc. T! ill"strate a patient s attit"de t!)ard therapyd. T! ill"strate the patient s "se !$ a("si'e lan&"a&e

7. Usin& In$!r+ati!n Ta3en $r!+ a ;a+ily Be+(er !r Si&ni$icant Other: 3hould state the exact relation of the patient to the informant Introduced before the actual statement

8. Ite+s Us"ally Incl"ded in the S"(=ecti'e C!ntent:a. C %here can be only 581 chief complaint> *elate to patient"s function as much as possible> If pain, state the following:

i. Onsetii. L!cati!niii. #"ality ay be in narrative or outline form

i. Narrati'e:Patient was apparently well until three days prior to consultation (P% ! when patientnoted J facial asymmetry with ironing out of wrin+les on the J side of the face %herewas associated inability to close the J eye completely, frequent lacrimation, droolingof liquid food on the J side of the mouth and difficulty in chewing food withaccumulation on the J side of the oral cavity %here was no Gyperacusis or abnormalear discharge Persistence of the problem prompted the patient to consult aphysiatrist one day after the onset Patient was diagnosed to have J 9ell"s Palsy andPrednisone and %ears 8aturale were prescribed Ge was then referred for P%

ii. O"tline:C days P% - noted J facial asymmetry and ironing out of wrin+les

- (M! associated incomplete eye closure J, frequent tearing J, drooling of liquid food J, difficulty in chewing food on J side of oral cavity


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- (-! hyperacusis4 (-! pain4 (-! ear discharge; days P% - consulted physiatrist due to persistence

- diagnosed with J 9ell"s Palsy- prescribed Prednisone and %ears 8aturale- good compliance with medications- advised P%

at present - no significant changes noted> Important *eminders &bout the GPI:

i. C!ntains (!th pertinent $indin&s present and a(sent in the patientii. Al)ays descri(es the $"ncti!nal stat"s !$ the patient (e$!re and a$ter the !nset

!$ the illnessiii. B"st (e arran&ed in chr!n!l!&ical !rder i'. B"st descri(e the clinical c!"rse !$ the illness

c. PBH: -past +edical hist!ry0> Includes other illnesses that:

i. Are 3n!)n ris3 $act!rs !$ the c"rrent diseaseii. Bay alter the clinical c!"rse !$ the c"rrent illness and th"s a$$ect pr!&n!sisiii. Bay a$$ect the +ana&e+ent !$ the patient

> 5ther items that may be included here:

i. ;DAii. S+!3in& H4.iii. Drin3in& H4.i'. Dr"& H4.

d. H;D: -heredit!$a+ilial diseases0> Presence of illness or state of health in the family (father, mother, brothers, and

sisters! and relativese. ;DA: -$!!d and dr"& aller&ies0$. H!+e Sit"ati!n:

> )iving arrangements> 'escribes the physical and social aspects of the home> Includes:

i. S"pp!rt syste+ii. En'ir!n+ental assess+ent

&. Pt. s Li$estyle:> Personal, social, and environmental history> ay include:

i. S+!3in& H4:ii. Drin3in& H4:iii. Dr"& H4:i'. Daily Acti'ities:'. !r3 Acti'ities:'i. Recreati!nal Acti'ities:'ii. Pre/+!r(id Stat"s:

h. Pt. s G!al:> &nticipated goals and expected outcomes for the patient$client

9. Special C!nsiderati!ns Re&ardin& S"(=ecti'e C!ntent in a Pediatric !r O(stetric Case

Gave additional componentsa. Pediatric Cases

> Includes:i. ,irth and +aternal hist!ry

- If patient is still a neonate, these are included in the GPI- Information obtained are:

i.a N"+(er !$ days p!st/deli'ery i$ ne!natei.( A&e !$ &estati!n -AOG0 at the ti+e !$ deli'ery and

i.& Presence


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iii. I++"ni ati!n hist!ry- Important in pediatric conditions that may be prevented through immunization

i'. De'el!p+ental hist!ry- Important in pediatric conditions presenting with developmental delay

(. O(stetric Cases> Includes:

i. Parityii. O(stetric sc!res


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II. O(tainin& and D!c"+entin& O(=ecti'e C!ntent I: Intr!d"cti!n t! O(=ecti'eData and the Syste+s Re'ie)A. Intr!d"cti!n t! O(=ecti'e Data

%he ob ective part of the note is the section in which the results of measurementsperformed and the therapist"s ob ective observations of the patient are recorded

5b ective data are the measurable or observable information used to plan patienttreatment%esting procedures that produce ob ective data are repeatable

,. Cate&!ri in& Ite+s as O(=ecti'e Data &n item is considered ob ective if:%. It is part !$ the patient s hist!ry ta3en $r!+ the +edical rec!rd and rele'ant t!

the pr!(le+. 8ot all facilities include information from the medical record 1xample:

5: Gx: &3G', G/, 5P' 3$P fx ()! hip c prosthesis insertion = yr*. It is a res"lt !$ the therapist s !(=ecti'e +eas"re+ents !r !(ser'ati!ns.

ust be measurable and reproducible data &re written in the ob ective part of a note but usually are summarized versions of thefollowing:

a. Data(ases(. ;l!) sheetsc. Chartsd. Speci$ic assess+ent $!r+s

If none of the above-mentioned forms are available, only pertinent (important! dataare to be written in the ob ective part

1xample:5: &*5 : 08) throughout 21s U )1s except ?V-=;?V ()! shoulder flexion noted

1. It is part !$ the treat+ent &i'en t! the patient. 'ata obtained here are written in other notes aside from the evaluation notes (interim

(progress! notes, discharge notes$summaries, turnover notes, and referral notes! Particularly:

a. B!di$icati!ns "sed(. N"+(er !$ repetiti!ns t!leratedc. Pain relie'ed !r ca"sed

%his provides information to anyone who might treat the patient as to what was donein a treatment session on a certain date

&lso done to inform both those reimbursing the treatment and those who might readthe medical record as a legal document of what was specifically done with the patient

1xample:5: P% x received:

= PL to (*! shoulder using #r I inferior glides, #r II distraction; &*5 exercises to (*! shoulder flexion-extension, abduction-adduction U medial

rotation-lateral rotation, =? reps W C sets each c F-secs isometrics X end-rangesC Ice massage to anterior, posterior, lateral U superior aspects of (*! shoulder W F

mins2. It is a patient ed"cati!n acti'ity.

2sually written in other notes aside from the evaluation notes any agencies accrediting patient care facilities are very interested in written

evidence of what P%s teach patients and families 1xample:

5: Patient 1ducation: *eceived instruction in home exercise program U was indep in sameprogram (attached!

C. Or&ani ati!n !$ O(=ecti'e Data2sing categories or headings ma+e information organized, easy to read, andeasy to find

ategories of headings can be based on:%. Types !$ tests and +eas"res per$!r+ed.

Gelpful when a patient has deficits on multiple areas or has a generalized problem 1xample:


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&mbulation%ransfers9alance*53trength3ensation

*. Areas !$ the (!dy and $"ncti!nal s3ills. Gelpful when a patient has deficits only on one or two parts of the body 1xample:

&mbulation &')21s)1s%run+

Placing ob ective data into categories or headings depends on:%. The dia&n!sis and de$icits !$ the indi'id"al patient.

%he therapist categorizes information in the manner that they deem most efficientand organized

2sed in some facilities only*. ;acility r"les and &"idelines !n d!c"+entati!n. %he therapist categorizes information on &)) patients in the same manner despite

differences in diagnoses and deficits between patients %he usual basis of placing items under a category$heading

ethods of using categories or headings:%. ;"ncti!nal cate&!ries $irst (e$!re n!n$"ncti!nal cate&!ries.

%he therapist presents functional categories before the nonfunctional categories ay also be presented with the functional category first then outlining directly after

the functional deficit the nonfunctional deficit(s! that contributed to the functional deficit ost preferred method by other readers of the note (e g physicians, third-party

payers, et al!*. N!n$"ncti!nal cate&!ries $irst (e$!re $"ncti!nal cate&!ries. %he therapist has to present first the nonfunctional categories that lead to a

functional deficit0ithin any individual category$heading, the following rules are followed:%. Or&ani e in$!r+ati!n in the +!st l!&ical !rder p!ssi(le.*. !ints are descri(ed !ne at a ti+e "s"ally in a cephal!/ca"dal +anner and

$r!+ pr!4i+al t! distal.D. C!++!n Bista3es in Rec!rdin& O(=ecti'e Data

3ome of the most common mista+es in recording ob ective data are:%. ;ail"re t! state the a$$ected part.*. ;ail"re t! p"t ite+s in +eas"ra(le ter+s.

If an item cannot be stated in measurable terms, the word .appears" instead of .is"should be used

3hould be used cautiously as third-party payers do not reimburse for interventionthat .appears" necessary

1. ;ail"re t! state the type !$ )hate'er it is that is (ein& +eas"red !r !(ser'ed.E. S!+e Speci$ics Re&ardin& Rec!rdin& O(=ecti'e Data

0hen using scales with numerical values, always include the normal value toma+e the ob of other people rearing the note for third-party payers easier

1xample:%: C$F versus fair

0hen using scales with analog values, always include the scale or rating system

used and the definition for each value 1xample:'eep %endon *eflexes: (5Yareflexia$absent4 M-hyporeflexia4 MMYnormoreflexia4 MMMYhyperreflexia MMMMYabnormal with = - C beats of clonus: MMMMMYabnormal with sustainedclonus!

1xample using a combined numerical$analog scale:Pain: F$=? using visual analog pain scale (Q&P3! (?Yno pain: =Yminimum perceivable pain4FY moderate pain4 =?Yworst possible pain!


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&bbreviations U edical %erminology%. Bini+i e "se !$ a((re'iati!ns and "se !nly "ni'ersally accepted a((re'iati!ns

!r the $acilityJs appr!'ed a((re'iati!ns.*. Use !nly appr!priate +edical ter+in!l!&y )ith c!rrect spellin&.

;. The Syste+s Re'ie) & briefer limited examination of:%. The anat!+ical and physi!l!&ical stat"s !$ the cardi!'asc"lar


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III. O(tainin& and D!c"+entin& O(=ecti'e C!ntent II: Tests and Beas"res inPhysical TherapyA. Intr!d"cti!n t! Tests and Beas"res

%he means of gathering data about the patient$clientPhysical therapists individualize the selection of tests and measures based on

the history they ta+e and systems review they perform, rather than basing their selection on a previously determined medical diagnosis/rom the history and systems review, the physical therapist determinespatient$client needs and generates diagnostic hypotheses that may be further investigated by selecting specific tests and measures %hese are used to rule outcauses of impairment and functional limitations4 establish a diagnosis, prognosis,and plan of care4 and select interventions%he tests and measures that are performed as part of an initial examinationshould be only those that are necessary to:%. C!n$ir+ !r re=ect a hyp!thesis a(!"t the $act!rs that c!ntri("te t! +a3in& the

c"rrent le'el !$ patient


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,. hat is Beas"re+ent &ccording to &P%&"s 3tandards for %ests and easurements in Physical %herapyPractice:

%he numeral assigned to an ob ect, event, or person 5* the class (category! towhich an ob ect, event, or person is assigned to according to rules

5btaining measurements is an everyday part of physical therapy practicePhysical therapists obtain many different types of measurements 1xamples of which are:%. Assessin& the +a&nit"de !$ a patient s rep!rt !$ pain*. #"anti$yin& +"scle per$!r+ance !r ran&e !$ +!ti!n1. Descri(in& the 'ari!"s characteristics !$ a patient s &ait pattern2. Cate&!ri in& the assistance that a patient re>"ires%he physical therapist collects data through many different methods, such as:%. Inter'ie)in&*. O(ser'ati!n1. #"esti!nnaires2. Palpati!n5. A"sc"ltati!n6. C!nd"ctin& per$!r+ance/(ased assess+ents7. Electr!physi!l!&ical testin&8. Ta3in& ph!t!&raphs and +a3in& !ther 'ide!&raphic rec!rdin&s9. Rec!rdin& data "sin& scales inde4es and in'ent!ries% . O(tainin& data thr!"&h the "se !$ techn!l!&y/assisted de'ices%%. Ad+inisterin& patient


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2. Disa(ilities s"ch as: Inability to engage in community, leisure, social, and wor+ roles

5. De'ice and e>"ip+ent need and "se s"ch as: &ssistive and adaptive devices 5rthotic, protective, and supportive devices

Prosthetic devices6. ,arriers s"ch as: 1nvironmental, home, and wor+ ( ob$school$play! barriers

In the evaluation process, the physical therapist synthesizes the examinationdata to establish the diagnosis and prognosis (including the plan of care! %hedata gathered through the use of tests and measures during initial examinationprovide information used for determining anticipated goals and expectedoutcomes %hese data may:%. Indicate initial a(ilities in per$!r+in& acti!ns tas3s and acti'ities*. Esta(lish criteria $!r place+ent decisi!ns and1. Identi$y le'el !$ sa$ety in per$!r+in& a partic"lar tas3 !r ris3 !$ in="ry )ith

c!ntin"ed per$!r+ance )ith !r )ith!"t de'ices and e>"ip+ent*eexamination at regular intervals during an episode of care enables thephysical therapist to measure and document:%. Chan&es in patient


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5ther /orms of *eliability:a. Parallel/$!r+ Relia(ility

> *elates to measurements that are obtained by using different versions of thesame test or measure

(. Internal C!nsistency *elates to measurements that are obtained by using tests or measures with

multiple items or parts, where each part is supposed to measure one, and onlyone, concept

*. alidity !$ Beas"re+ents%he degree to which a useful (meaningful! interpretation can be inferred from ameasurement/orms of Qalidity:

a. ;ace alidity> 1xists when the measurement seems to reflect what is supposed to be measured

6 but it does not depend on evidence> 1xample: goniometric measurements 6 have face validity as measurements of

oint position

(. C!ntent alidity> 1stablishes the degree to which a measurement reflects the domain of interest> 1xample: instruments to assess oint pain 6 might generate data only regarding

pain on motion, not pain at rest or factors that aggravate or alleviate painc. C!nstr"ct alidity

> & theoretical form of validity that is established on the basis of evidence that ameasurement represents the underlying concept of what is to be measured

> 1xample: the overall concept of .motor function" is the construct that underliesany particular test or measure of motor function

> %here are no direct tests of construct validity %heoretical evidence of constructvalidity is often provided by demonstrating convergence if tests or measuresbelieved to represent the same construct are highly related

>

1xample of onvergence: a test of motor function, based on a particular conceptof what .motor function" means, should correlate highly with other tests or measures based on similar conceptions of .motor function" or on concepts thatare closely related to .motor function," such as .dexterity and coordination "

> 1vidence of construct validity is also found when there is a low association, or divergence, between a test or measure of one particular construct and other testsor measures reflecting distinctly different, or even unrelated, constructs

> 1xample of 'ivergence: there should be low association between a test of .motor function" and tests and measures that are based on the concepts of .aerobicconditioning" or .range of motion "

d. C!nc"rrent alidity> 1xists when an inferred interpretation is ustified by comparing a measurement

with supporting evidence that was obtained at approximately the same time asthe measurement being validated> 1xample: developers of a new balance test might compare the measurements

obtained using the new test to those obtained using an established balance testinvolving one-legged stance

> %he comparative method of establishing concurrent validity is particularlyrelevant for self-assessment instruments

e. Predicti'e alidity> 1xists when an inferred interpretation is ustified by comparing a measurement

with supporting evidence that is obtained at a later point in time and examinesthe ustification of using a measurement to say something about future events or conditions

> Tnowing the predictive validity of a measurement may facilitate the identificationof achievable outcomes and increase the efficiency of discharge planning

> 1xample: predictive validity of a measurement of functional capacity might beestablished by verifying whether the measurement indicates the li+elihood of return to wor+

> Predictive validity may also provide the physical therapist of information aboutthe value of selecting particular tests or measures for the examination, such as:i. Sensiti'ity !$ a Beas"re+ent

- Indicates the proportion of individuals with a positive finding who already have or will have a


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and !ther interested pe!ple%he list of these categories of tests and measures, including the informationstated above, may be seen in &ppendix IQ

;. I+p!rtant Tests and Beas"res in Generali ed C!nditi!nsoncentrate examination of the patient on the items listed below each

generalized condition%. B"sc"l!s3eletal C!nditi!ns 5bservation of:

a. General attit"de !$ patient(. General p!st"rec. illin&ness t! +!'ed. Gaite. O('i!"s de$!r+ities -a(n!r+al c"r'at"res =!int s"(l"4ati!n asy++etrical

(!dy c!nt!"rs s)ellin& and c!l!r and te4t"re !$ s3in0> If the above are present, a more detailed examination is necessary

Palpationa. Areas !$ pain and tenderness

(. Areas !$ restricti!nc. S)ellin&d. Anat!+ical !rientati!n !$ str"ct"res

&*5 P*5 3trength /lexibility (including oint play and muscle length tests! /unctional tests (&') and I&')! 3pecial tests 5ther diagnostic procedures

*. Ne"r!+"sc"lar C!nditi!ns &rousal, attention, and cognition ommunication /unctional tests (&') and I&')! otor control %one 3ensation and perception /lexibility

1. Cardi!p"l+!nary C!nditi!ns ardiovascular diagnostic tests and procedures Pulmonary diagnostic tests and procedures

2. Inte&"+entary C!nditi!ns Integumentary integrity and condition (including vascular compromise, trauma,

disease, and scar tissue!In any condition, always chec+ for presence or ris+ of secondary complications3pecial onditions:

*equire additional tests and measures%. Pediatric C!nditi!ns

'evelopmental milestones*. Geriatric C!nditi!ns

#enerally, all categories of tests and measures are included


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IK. Ele+ents !$ Patient


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of impairments &s in all other cases, the physical therapist is guided by patient$client responsesto those interventions and may determine that a reexamination is in order and proceedaccordingly

%he ob ective of the physical therapist"s diagnostic process is the identification of discrepancies that exist between the level of function that is desired by the patient$client and thecapacity of the patient$client to achieve that level In carrying out the diagnostic process,physical therapists may need to obtain additional information (including diagnostic labels! fromother professionals In addition, as the diagnostic process continues, physical therapists mayidentify findings that should be shared with other professionals (including referral sources! toensure optimal care If the diagnostic process reveals findings that are outside the scope of thephysical therapist"s +nowledge, experience, or expertise, the physical therapist refers thepatient$client to an appropriate practitioner

a+ing a diagnosis requires the clinician to collect and sort data into categoriesaccording to a classification scheme relevant to the clinician who is ma+ing the diagnosis%hese classification schemes should meet the following criteria:

a. Classi$icati!n sche+es +"st (e c!nsistent )ith the (!"ndaries placed !nthe pr!$essi!n (y la) -)hich +ay re&"late the applicati!n !$ certain types!$ dia&n!stic cate&!ries0 and (y s!ciety -)hich &rants appr!'al $!r +ana&in& speci$ic types !$ pr!(le+s and c!nditi!ns0.

(. The test and +eas"res necessary $!r c!n$ir+in& the dia&n!sis +"st (e)ithin the le&al p"r'ie) !$ the health care pr!$essi!nal.

c. The la(el "sed t! cate&!ri e a c!nditi!n sh!"ld descri(e the pr!(le+ in a)ay that directs the selecti!n !$ inter'enti!ns t!)ard th!se inter'enti!nsthat are )ithin the le&al p"r'ie) !$ the health care pr!$essi!nal )h! is+a3in& the dia&n!sis.

%he preferred practice patterns in &P%&"s #uide to Physical %herapist Practicedescribe the management of patients who are grouped by clusters of impairments thatcommonly occur together, some of which are associated with health conditions that impedeoptimal function 1ach pattern represents a diagnostic classification %he pattern title thereforereflects the diagnosis 6 or impairment classification 6 made by the physical therapist %hediagnosis may or may not be associated with a health condition for patients$clients who areclassified into that pattern

%he physical therapist uses the classification scheme of the preferred practicepatterns to complete a diagnostic process that begins with the collection of data (examination!,proceeds through the organization and interpretation of data (evaluation!, and culminates in theapplication of a label (diagnosis!

'iagnostic labels are placed in the Impressions$3ummary section of the &ssessmentportion of a 35&P note

%he list of these Physical %herapy diagnostic labels may be seen in &ppendix Q1. Pr!&n!sis -incl"din& Plan !$ Care0

a. Pr!&n!sis>

%he determination of the predicted optimal level of improvement in function andthe amount of time needed to reach that level> ay also include a prediction of levels of improvement that may be reached at

various intervals during the course of therapy> Prognosis is documented in the &ssessment part of a 35&P note as the

outcomes and goals ()ong-%erm #oals$1xpected /unctional 5utcomes and3hort-%erm #oals!

(. Plan !$ Care> onsists of statements that specify the anticipated goals and expected

outcomes, predicted level of optimal improvement, specific interventions to beused, and proposed duration and frequency of the interventions that are requiredto reach the anticipated goals and expected outcomes

>

%herefore describes:i. Speci$ic patient


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severity, complexity, and acuity of the pathology$pathophysiology (disease,disorder, or condition!, the impairments, the functional limitations, and thedisabilities to establish the prognosis and prediction about the li+elihood of achieving the anticipated goals and expected outcomes

> %he plan of care identifies anticipated goals and expected outcomes, ta+ing intoconsideration the expectations of the patient$client and appropriate others (If required, the anticipated goals and expected outcomes may be expressed asshort-term and long-term goals ! &nticipated goals and expected outcomes arethe intended results of patient$client management and indicate the changes inimpairments, functional limitations, and disabilities and the changes in health,wellness, and fitness needs that are expected as the result of implementing theplan of care %he anticipated goals and expected outcomes also address ris+reduction, prevention, impact on societal resources, and patient$clientsatisfaction %he anticipated goals and expected outcomes in the plan should bemeasurable and time limited

> %he plan of care includes the anticipated discharge plans In consultation withappropriate individuals, the physical therapist plans for discharge and providesfor appropriate follow-up or referral %he primary criterion for discharge is theachievement of anticipated goals and expected outcomes 0hen physicaltherapy services are terminated prior to achievement of anticipated goals andexpected outcomes, patient$client status and the rationale for termination aredocumented /or patients$clients who require multiple episodes of care, periodicfollow-up is needed over the life span to ensure safety and effective adaptationfollowing changes in physical status, caregivers, environment, or tas+ demands

> %hus, Plan of are encompasses the &ssessment and Plan portions of a 35&Pnot

Documents

Intro Clin Manual v2