PTE second half

Why is documentation important

Our guide to clinical decision making (diagnosis, prognosis, treatment plan)

Communication between disciplines and care providers

Provides record of services provided

Improves consistency in care

Third party payment (justifies need for care)

Components of examination

Reason for referral (pt interview)

Activity or functional assessment

Tests and measures

Assessment statement (diagnosis, prognosis, need for PT)

Plan of care

Order of patient client management model

Examination (reason for referral, activities, impairments)

Evaluation (assessment)

Diagnosis/prognosis (assessment)

Intervention (goals)

Outcomes (plan of care)

ICF model

Health condition (reason for referral)

Body structure and function (tests and measures), activity, participation (reason for referral)

Environmental factors, personal factors (both contextual factors and fall under reason for referral)

What kind of information do we have in movement assessment + examples

Qualitative information (quality of the movement)

• Were they successful

• Typical or atypical

• Optimal or suboptimal

Quantitative information (time it takes)

When do you create your hypothesis

Between examination and evaluation

Human movement systems chart from inside to outside

Cardiovascular, pulmonary, endocrine

Musculoskeletal, nervous

Integumentary

Also communication/cognition/learning style (not on the chart but important)

What does assessment statement contain

History and impact of contextual factors

Diagnosis (both process and product of that process)

Statement of prognosis (I think with pt we can restore…)

Process vs product

Process: the investigation or analysis of the cause or nature of the condition

Product: statement or conclusion from the analysis that links what we found to their activity or participation limitations

Purpose of the assessment section

1. Summary of eval and clinical judgement of the condition

2. Diagnosis which could confirm, extend, or question referral diagnosis. Link everything together

3. Justification of necessity of PT (PROGNOSIS)

SMART goal

Specific

Measurable

Attainable

Relevant

Time based