16. DPT 730: Documentation: Objective exam, SMART goals

Elements of a "solid foundation" during the PT examination? (2)

Patient history

Tests and measures

The OSPRO ROS tool is a subjective review of systems that screens for...

Red flags

How does direct access change our responsibility as clinicians?

Pts might need care that's outside our scope, so we must screen for red flags

During what portion of the exam should the systems review occur?

Embedded throughout exam as it comes naturally

What are some examples of systems review components that occur naturally throughout the systems review? (2 examples)

Vitals = Cardiopulmonary review

Palpation = Integumentary

How to prepare for selecting tests and measures (3 steps)

1. Gather info (patient history, systems review)

2. Hypothesize diagnosis

3. Conduct appropriate tests and measures

Considerations for picking an exam (4)

Is it a valid + reliable test?

Is it appropriate for pt?

Can my pt tolerate this test?

Cost and time investment of test

Categories of tests that we may use to gather data (6)

Activity completion tests (ex. ADLs)

Impairment tests (ex. pain)

Observational (ex. posture, gait)

Anthropometrics (ex. height/weight)

Neuro (ex. dermatomes)

MSK (ex. MMTs)

What is the most commonly reported pt issue in PT?

Pain

PQRST method of documenting pain (what do they each stand for?)

Provoking factors

Quality

Region

Severity

Time of day

Is the experience of pain the same for everybody?

No, pain is a personal experience influenced by biopsychosocial factors

What is the term for the perception of pain?

Nociception

Can pain be influenced by lifetime experiences?

Yes, pain can be learned via life experiences

As a PT, are we allowed to ignore or dismiss any reports of pain?

No, all reports of pain deserve respect

Can the pain experience change over time?

Yes, pain is adaptive

If a pt cannot express pain, does it mean that they aren't experiencing pain?

No, inability to express pain does not mean it doesn't exist

Name factors that can influence the perception of pain (6)

Influenced by...

Physiological

Sensory

Affective

Cognitive

Behavioral

Sociocultural

factors

How can catastrophizing pain change outcomes?

Patients who catastrophize pain may experience worse outcomes

Main difference between systemic and MSK pain?

Systemic pain more constant

MSK pain typically brought on by specific movements

Common descriptive words for muscle pain? (4)

Cramping

Dull

Aching

Increases w/contraction or stretching

Descriptors for ligamentous or joint capsular pain (2 terms)

Dull

Aching pain

Descriptors for nerve root pain (3 terms)

Sharp

Shooting

Follows dermatomes

Descriptors for peripheral nerve pain (3 terms)

Sharp

Bright

Follows peripheral nerve description

Descriptors for sympathetic nerve pain (4 terms)

Burning

Pressure-like

Stinging

Aching

Descriptors for bone pain (4 terms)

Deep

Boring

Dull

Localized

Descriptors for fracture pain (3 terms)

Sharp

Severe

Intolerable

Descriptors for vasculature pain (2 terms)

Throbbing

Diffuse pain

Define nociceptive pain

Pain that arises from actual or threatened damage to non-neural tissue

Types of nociceptive pain (3)

Mechanical, inflammatory, ischemic

Define neuropathic pain

Pain caused by a lesion or disease of peripheral somatosensory system

Define standardized tests and measures

"Outcome measures", standard tests that we use for certain conditions

Types of standardized outcome measures (3) (What are they measuring?)

Condition-specific

Body system-specific

Activity-specific

What section of documentation do we report standardized outcome measures in?

Objective measures

Goals should be... (3 factors)

Measurable, functionally driven, time limited

What is the relationship between goals, medical necessity and PT?

Good goals demonstrate both medical necessity and the need for skilled PT interventions

Elements of a SMART goal (what does SMART stand for?)

Specific

Measurable

Assignable

Realistic

Time-bound

When writing goals, you must consider these factors (6) (basically who, what, where, when, why?)

Target audience

Description of activity

Connection of activity to function

Conditions of activity

Factors for measuring performance

Timeframe for achieving goal

Efficiency formula for writing goals (full sentence)

The patient (assignable) will _____ (specific, measurable, realistic achievement of functional ability) within _______ (realistic time frame) in order to improve the pt's ability to ______ (functional impact).

Goals are dynamic. When do we need to change goals?

Change of status

Reevaluation

What should be the basis of all goals made in PT?

To reduce functional limitations and promote better QoL