History and Goal Writing

Where does history fit in the process?

patient examination before hands on examination

What are key interview skills to help take a history?

Build rapport, listen actively, elicit change with patient-driven goals

What are aspects of building rapport?

introduction, environment, collaboration

What are aspects of listening actively when taking a history?

open vs closed questions, clarifying, summarizing

What are aspects of using your body language that can help with the history process?

posture, lean forward slightly, be on level with client

What are non-verbal cues that can be useful in creating a good environment for history taking?

eye contact, relaxed, calm, try not to appear in a hurry, use of body language

When are close ended questions useful in histroy taking?

useful if needing to pinpoint responses and when time is a concern

What demographic information should be included in a history?

age, occupation, ADL, developmental milestones, primary language, education

What are the different sources we may be getting info from?

Client, family/caretaker, chart, face sheet, electronic medical record

What questions may be relevant when discussing chief complaint or history of current condition?

What brings you in?

When did it begin?

Previous history of complaint?

Has it changed over time?

When discussing when the complaint begin, what are aspects that may need to be considered?

Sudden onset- injury, non-traumatic

insidious onset- cumulative, predisposing factors, systems review

What are ways a pt may describe nerve pain?

sharp, burning, shooting, stinging

What are ways a pt may describe bone pain?

deep, localized, boring

What are ways that a pt may describe vascular pain?

diffuse, aching, poorly localized, throbbing

What are ways that a pt may describe muscular pain?

hard to localize, dull, aching, cramping

What are ways that a pt may describe pain from a fracture or tumor?

sharp, severe, intolerable, unrelenting

What are aspects we may ask about with pain?

location, pattern, intensity, quality, duration, frequency

When considering chief complaint, what is one aspect that we need to consider?

functional impact

If appropriate, when asking about living environment, what may be asked about?

Stairs, ramps, uneven terrain, assistive equipment within home, use of community services

What are life stressors that may impact healing that can be gleaned through the history?

work, home, financial, marital, parental, coping strategies

What aspects should we ask about pertaining to social history?

family/caregiver support, social activities, living environment, community, role, religious beliefs

What do we need to know about medications?

meds currently taking for this problem, previously taken for current condition, currently taking for other conditions

What aspect of the pt history can be considered to have lifelong ramifications of a health history?

past medical history

What should be identified in the wellness component of the history?

Health risks, fitness/activity level, past/current/future wellness activity options

What are sensitive topics that may need to be addressed in the history?

impact on intimacy, bladder leakage, fear, mental health and emotional well-being, autonomy/independence, substance use, PTSD, trauma, social history, abuse

What are ways we can ask about client’s/family’s goals and expectations?

What do you hope to achieve with PT?

If we could fix one thing for you today, what would you choose?

What do you do with the information or how may it shape further examination?

Shapes exam, guides hypothesis, informs goals/interventions

What is our job as clinicians when it comes to going from the interview to clinical note?

Translate what you hear into clear, meaningful clinical information

What questions can we ask during history taking when we are listening for meaning?

What is the main problem?

How is it affecting function?

How will context challenge or optimize?

What can be edited when translating from pt story to clinical note in history taking>

Removed filler language, estimated timeframe, identified limitation, used concise/professional phrasing

What are writing principles for the subjective?

Be concise, use neutral/professional language, prioritize function, quantify when possible, use patient quotes selectively

What are the ABCs of goal writing?

Actor, behavior, conditions, degree, expected time, functional

What expanded goal concepts fall under the specific umbrella of a SMART goal?

Actor and behavior

What expanded goal concepts fall under the measurable umbrella of a SMART goal?

Degree and conditions

What expanded goal concepts fall under the relevant umbrella of a SMART goal?

Functional

What expanded goal concepts fall under the time-based umbrella of a SMART goal?

expected time

What are types of behavior that can be addressed in goal writing?

Run, transfer, type on computer, pull up pants