Patient Care Notes
record what the therapist does to manage the individual patient's case
can be used in outcomes research
Disposition
last/present status of pt
after every session based on Sx. of pt
based on objective findings and response therapy
Initial Evaluation
initial note written after pt.'s first examination and evaluation, documents history, examination, evaluation, diagnosis, prognosis. and poc; need for pt's referral; goals, problem list.
Progress Notes
written periodically, recording results of examination and re-evaluation, changes in prognosis, poc as needed.
Discharge Notes
PT discontinued care, pt is discharged from therapy, after a final exam and evaluation is performed.
PT Notes
irregular documentation of pt's, in between sessions, documentation of what transpired during session, SOAP format, w/o history taking.
Subjective Objective Assessment Plan
SOAP
Subjective
includes CC of pt, HPI, Family Medical, Personal, and Environmental History.
Objective
results from pt.
Assessment
summary from subjective and objective parts.
Plan
what they need to do w/ pt. based on evaluation.
General Information
being taken bc it is needed for pt's demographic info/identifying information, can help identify what lead to that injury, etc.
Chief Complaint
should be specific area, pain scale, what type of pain, etc
PT should know what to do functionally, and what pt can't do functionally
Patient Goals
PT should know pt's goal.
History of Present Illness
details pt’s CC from w/c they are seeking medical attention as well as unrelated functional deficits, should explore other info related to CC such as recent and past medical/surgical history, complications of treatment, potential restrictions/precautions and mechanism of injury.
Ancillary Procedures
medical tests, results affecting pt’s condition or treatment ex: xray, mri, ct scan; aligned to pt’s condition, specific and sensitive to pt’s condition.
Medical/Drug History
drugs taken by pt in relation to injury, as well as supplements and maintenance drugs.
Past Medical History
present or recent diagnosis outside present injury.
Family History
hereditary diseases, sensitive to cases to systemic or neurologic in nature.
Personal, Social, and Environmental Hx
talks more about set up of pt.
Objective
results of tests and measures performed and the therapist's objective observations of the patient are recorded
measurable or observable information used to formulate the plan of care
repeatable
Examination
used to confirm or refute the suspected diagnosis, which is based on the history and observation
must be performed systematically with PT looking for a consistent pattern of S/Sx that lead to a differential diagnosis
Stereognosis
ability to recognize objects helped by the hand without vision.
Barognosis
ability to recognize weight.
Cadence
number of steps per minute.
PT Impression
contains the patient’s MD diagnosis, a summary of all the impairments listed in the O part, and its implication to the patient's level of function.
Problem List
a list of all the impairments noted in the observation section
list of complaints of the patient or the problems that you found in the assessment. This includes the subjective and objective measurements
Prognosis
include justification for further therapy for a patient who initially appears relatively independent with one functional activity as well as the projected level of improvement based on patient and case related factors./
Prognosticating Factors
basis how to determine the prognosis of the pt.
Positive Prognosticating Factors
facilitate patient's recovery.
Negative Prognosticating Factors
hinder patient's recovery and improvement even with therapy.
Long Term Goal
describes the final product to be achieved by therapy
these outcomes are listed in terms of function
Short Term
are interim goals that needs to be achieved to be able to achieve the long term goal.
AUDIENCE BEHAVIOR CONDITION DEGREE
ABCD of goal writing.
Audience
almost always, the patient is the audience. However, it can be a family member or the patient with family member.
Behavior
is always an action verb, often followed by the object of the behavior
the object of the behavior must be something that can be measured or described accurately so that you can document when these outcomes are achieved
Condition
includes the circumstances under which the behavior must be done or the conditions necessary for the behavior to occur.
Degree
it includes the minimal number
the percentage or proportion
any limitation or departure from a fixed standard
any distinguishing features of successful performance
this should be realistic, measurable, and observable in term of function
Specific Measurable Attainable Realistic Time Bound
a goal must be SMART
Plan
contains all the pt management as well as the time frame and schedule that the patient will be seen and treated.