Documenting Clinical Problem Solving

What are patient-identified problems?

• Almost always function things the patient complains about

• Ex: “My shoulder hurts”, “I can’t brush my hair”, “I can’t get out of my chair”

What are non-patient-identified problems?

• Comes from the caregiver/family

• Seen in tests & measures

• Must have measured the problem for it to become a goal or receive an intervention

• Interprofessional team

What is classified as impairments?

• Something wrong with body function

• Ex: strength, ROM, balance, endurance

What are classified as activities?

• Functional tasks the patient can/can’t do

• Ex: bed mobility, balance, walking

What is classified as participation?

• Patient’s roles in their life

• Ex: family, household duties, work duties, money management, driving, recreational hobbies

What is the purpose of using tests & measures?

• Helps objectively identify/measure impairments, activity limitations, and participation restrictions

• Confirms or rejects hypothesis about patient’s problems

• Supports diagnosis, prognosis, and helps develop a plan of care

What are long-term goals?

• Expected outcomes at the end of care (discharge)

  • Days, weeks, months

• Meaningful to the patient = functional for them

• Ex: can reach the cabinet, can wash their hair, etc.

What are short-term goals?

• Achievable in shorter time & build to long-term goals

  • Days, visits, weeks

• Must be meaningful to the patient = functional

What are interventions?

Plans for treatment based on the PT’s findings, diagnosis, and goals

What factors influence interventions?

• Psychosocial & economic factors

• Patient’s overall health status

• Adherence to intervention program

What are procedural interventions?

• Adaptive & assistive technology

• Biophysical agents

• Functional training

• Integumentary repair & protection techniques

• Manual therapy

• Motor function/movement training

• Respiratory & ventilatory techniques

• Therapeutic exercises

How should you write the evaluation summary?

• The patient presents with (IMPAIRMENTS) resulting in difficulty performing (ACTIVITY LIMITATIONS) due to (HEALTH CONDITION).

• The patient is unable to (PARTICIPATION ROLE).

• The patient has (IMPACT OF ENVIRONMENTAL & PERSONAL FACTORS).

• The patient will benefit from skilled PT to be able to (ACTIVITY OR PARTICIPATION ROLE).