Physical Therapy Documentation: Subjective and Objective Data

Flashcards covering subjective and objective data, examples, and documentation strategies in physical therapy.

Subjective Data includes

Pt c/o pain and symptoms

Pt difficulties with hep

Patient response to previous treatment,

Patient functional improvements that they noticed

Patient lifestyles , living situation , hobbies

Caregiver response

Objective Data includes

-measurements and tests,

- Therapeutic exercises such as the amount of sets and reps

• Documentation of the assist devices that were used. Like wheelchair, walkers, gait belt, crane

a description of patient assist level when performing transfers, and bed mobility

Patient instruction with hep

Patient education with their precautions

Wound description

Strategies for Writing Subjective Data

Documentation guidelines requiring that irrelevant information be excluded, only information affecting interventions/goals or proving treatment effectiveness be included, pain information be recorded, and caregiver reports be included if indicated.

assessment data include

Patient response to the inventions

Parents progress towards short term and long terms goals

Explanation on why the invention were nesscary

Physical Therapy Interventions

Treatments documented under objective data, including physical agents and modalities, therapeutic exercises, wound care, functional training (such as gait using assistive devices), patient education/instruction, and coordination with other disciplines.

Patient Function (Objective Data)

Objective descriptions of functional movement abilities, such as performing transfers, gait on even or uneven surfaces (with or without assistive devices), standing, or bed mobility (such as turning from supine to side-lying to sitting).

PTA Objective Observations

Observations made by the PTA during interventions, tests, measurements, and education, such as an increase in exercise repetitions, compensating for muscular weakness, and understanding the HEP on the first try.

Home Exercise Program (HEP)

A prescribed exercise program whose compliance or difficulties are documented under subjective data, and whose patient understanding is documented under objective observations.