Overview of Physical Therapy Assessment and Documentation

What is the first step in the cycle of assessment in physical therapy?

Examination, which involves obtaining a history, performing a systems review, and selecting tests and measures to gather data about the patient.

What does the evaluation step in the assessment cycle involve?

Making clinical judgments based on the data gathered during the examination and identifying possible problems that may require consultation or referral.

What is the purpose of the diagnosis step in the assessment cycle?

To evaluate examination data, organize it into defined clusters or categories, determine prognosis, and identify appropriate intervention strategies.

What does prognosis in physical therapy entail?

Determining the level of optimal improvement that may be attained through intervention and specifying the timing and frequency of interventions.

What is the focus of the intervention step in the assessment cycle?

Purposeful and skilled interaction of the PT with the patient, using various methods and techniques to produce changes consistent with the diagnosis and prognosis.

What are outcomes in the context of physical therapy?

The results of interventions, including the impact on pathology, impairments, functional limitations, and patient satisfaction.

What are body structures and functions in the ICF framework?

Components that are assessed subjectively and objectively during the examination, including impairments at the body structure/function level.

What are impairments in the context of the ICF framework?

Issues at the body structure/function level, often resulting from medical diagnoses, such as pain, swelling, or weakness.

What are functional activities according to the ICF framework?

Activities a person has trouble performing due to their diagnoses and body structure/function impairments, often referred to as functional limitations.

What does participation refer to in the ICF framework?

The significance of a patient's functional limitations in their life, such as being unable to care for children or perform work-related tasks.

What are some examples of environmental factors in the ICF framework?

Physical safety, social factors, household activities, noise, air quality, and health system accessibility.

What are personal factors in the ICF framework?

Individual characteristics that affect health, such as motivation, exercise knowledge, social support, stress, and health insurance.

What is the role of reexamination in the intervention step?

To determine changes in patient status and modify or redirect intervention based on new clinical findings or lack of progress.

What is the significance of documenting in physical therapy?

Documentation is essential for tracking patient progress, justifying interventions, and ensuring continuity of care.

What types of data are collected during the examination phase?

Patient history, systems review, and specific tests and measures.

How does the PT determine the prognosis?

By evaluating the examination data and determining the expected level of improvement and the time required to achieve it.

What might trigger a PT to consult or refer to another provider?

Identifying problems during the examination or evaluation that require expertise beyond the PT's scope.

What is the relationship between impairments and functional limitations?

Impairments at the body structure/function level lead to functional limitations in activities.

How can environmental factors impact a patient's rehabilitation?

They can either facilitate or hinder the patient's ability to engage in activities and participate in society.

What is the importance of patient satisfaction in the outcomes of physical therapy?

It reflects the effectiveness of interventions and the overall impact on the patient's quality of life.

What types of questions or tests are used to assess body structures and functions?

Specific questions and standardized tests that evaluate impairments and functional capabilities.

Why is understanding personal factors important in physical therapy?

Personal factors can influence a patient's motivation, adherence to treatment, and overall health outcomes.

What is the primary purpose of documentation in physical therapy?

To record the patient's health status and track healthcare episodes.

How does documentation serve as a communication tool in physical therapy?

It relays clinical reasoning in a written form between providers.

What legal requirements does documentation help meet in clinical practice?

It aids in risk management, regulatory compliance, and payer requirements.

What is the significance of the phrase 'if it wasn't written down, it didn't happen' in documentation?

It emphasizes the importance of written records for legal protection and accountability.

What are some purposes for which documentation may be used beyond patient care?

It may be used for policy development or research purposes.

What does the 'S' in the SOAP note format stand for?

Subjective, which includes information from the patient or family about the patient's feelings and symptoms.

What types of information are included in the Subjective section of a SOAP note?

Patient's description of symptoms, mechanism of injury, functional levels, home situation, expectations, and reflections on treatment.

How should information in the Subjective section be recorded?

In narrative form, with paraphrasing and quotations used only as needed.

What does the 'O' in the SOAP note format represent?

Objective, which includes observable data obtained through direct testing.

What kind of data is recorded in the Objective section of a SOAP note?

Actual treatment provided, patient education, specific changes in measurements, and observations of patient status.

What does the 'A' in the SOAP note format signify?

Assessment, which includes the clinician's professional judgment and evaluation of the patient's condition.

What components are included in the Assessment section of a SOAP note?

PT diagnosis, prognosis, short and long-term goals, and follow-up assessments.

What does the 'P' in the SOAP note format stand for?

Plan, which outlines the planned interventions and treatment strategies.

What information is typically included in the Plan section of a SOAP note?

Specific treatment modalities, frequency, duration, and plans for consultations or referrals.

What should the SOAP summary reflect regarding the Subjective section?

It should reflect the patient's self-report and responses to previous treatments, along with data from medical records.

What is included in the Objective summary of a SOAP note?

The PT's objective findings, measurements, tests, treatment provided, and patient response on that date.

What does the Assessment summary in a SOAP note entail?

It includes the PT's clinical decision-making, assessment of the patient's condition, progress, and functional limitations.

What should the Plan summary provide in a SOAP note?

Specific information related to future services, education, and potential changes in the treatment program.

What is the ABCDEF method used for in goal setting?

It is a framework for defining short- and long-term goals.

What does 'A' in the ABCDEF method refer to?

Audience/actor, specifying who will perform the behavior.

What does 'B' in the ABCDEF method indicate?

Behavior, which describes the activity to be performed.

What does 'C' in the ABCDEF method stand for?

Condition, outlining the circumstances under which the behavior will occur.

What does 'D' in the ABCDEF method represent?

Degree, indicating how much change is expected.

What is quantification in physical therapy goals?

It refers to specifying measurable outcomes, such as '20º' or '100 feet with min assist'.

How is expected time defined in physical therapy goals?

It indicates how long it will take to reach a goal, expressed in days, weeks, months, or number of visits, e.g., 'within 2 weeks'.

What is the purpose of relating a goal to a specific functional activity?

To clarify the practical application of the goal, such as 'in order to comb hair' or 'to get to the bathroom'.

Provide an example of a measurable patient goal in physical therapy.

The patient will ambulate on level surfaces with a FWW and min A for 100 feet within 1 week, in order to get to the bathroom at home.

Define Range of Motion (ROM).

ROM is the arc of motion between the beginning and end of a motion in a specific plane.

What is the difference between Active Range of Motion (AROM) and Passive Range of Motion (PROM)?

AROM is movement produced by voluntary unassisted muscle contraction, while PROM is movement produced by an external force without patient assistance.

What does AAROM stand for and how is it defined?

AAROM stands for Active Assisted Range of Motion, which is range of motion assisted by an outside force.

What information can AROM provide about a patient?

It indicates the patient's willingness to move, gross strength, coordination, joint ROM, and insight into potentially injured structures.

Why is AROM tested before PROM?

To assess the patient's voluntary movement capabilities before evaluating passive movement.

What does a significant difference between PROM and AROM indicate?

If PROM is significantly greater than AROM, it may indicate weakness.

List some impairments that assessing ROM can help determine.

Flexibility, strength, motor control, and functional limitations.

What is the purpose of measuring ROM in physical therapy?

To identify impairments, relate them to functional limitations, determine injured tissues, and assess treatment effects.

What is a goniometer and how is it used?

A goniometer is a device used to measure joint angles, with a stationary arm aligned with the proximal segment and a movable arm aligned with the distal segment.

What is the standard instrument for measuring spine ROM?

Inclinometry is the standard for measuring spine ROM.

What are some alternatives to goniometry for measuring ROM?

Body landmarks or measuring tape can be used for quicker, functional assessments.

How does assessing joint ROM differ from assessing muscle flexibility?

Joint ROM measures the amount of movement possible at a joint, while flexibility assesses the ability of soft tissues to lengthen and allow movement.

Define muscle length in the context of flexibility.

Muscle length is the greatest extensibility of a muscle-tendon unit, measured as the maximal distance between the proximal and distal attachments of a muscle to bone.

What is end-feel in ROM assessment?

End-feel is the sensation perceived by the examiner as the barrier to further ROM, felt when applying slight overpressure.

What factors affect end-feel during assessment?

The type of structure limiting the ROM and the patient's tolerance to motion.

What are the normal types of end-feel?

Soft, firm, and hard end-feels, each with specific descriptions and examples.

Describe a soft end-feel and provide an example.

A soft end-feel occurs when soft tissue meets soft tissue, such as in knee flexion.

What characterizes a firm end-feel?

A firm end-feel is described as a muscular or capsular stretch, such as hip flexion with the knee straight.

What does a hard end-feel indicate?

A hard end-feel indicates bone contacting bone, such as in elbow extension.

What are the abnormal end feels in elbow extension?

Soft, Firm, Hard, Empty.

What does a soft end feel indicate?

Occurs sooner or later in the ROM than is usual, or in a joint that usually has a different end-feel, often due to soft tissue edema or synovitis.

What does a firm end feel indicate?

Increased muscular tone or capsular, muscular, ligamentous, or fascial restriction.

What conditions are associated with a hard end feel?

Chondromalacia, osteoarthritis, loose bone fragments in the joint, myositis ossificans, or fracture.

What does an empty end feel signify?

No real end-feel due to pain or apprehension preventing reaching the end of the ROM, often associated with acute joint inflammation, bursitis, abscess, or fracture/dislocation.

When is ROM assessment warranted?

When there are impairments in flexibility, strength, motor control, or to relate ROM impairments to functional limitations.

What are the purposes of ROM assessment?

To track progress objectively, justify PT services, and make appropriate splint/brace.

What are contraindications to ROM testing?

Joint dislocation/subluxation, fracture, tendon/ligament rupture, acute infection or inflammation, severe osteoporosis, and current healing processes.

What internal factors can impact ROM?

Muscle length, age, sex, and passive insufficiency.

What external factors can affect ROM?

Body habitus, occupational activities, recreational activities, hand dominance, test position, patient comfort, type of instrument, examiner experience, time of day, and stage of recovery.

What is the typical ROM for hip flexion in adults?

120º with a soft end feel.

What is the typical ROM for hip extension in adults?

20º with a firm end feel.

What is the typical ROM for knee flexion in adults?

135º with a soft end feel.

What is the typical ROM for ankle dorsiflexion in adults?

20º with a firm end feel.

What is the typical ROM for cervical flexion in adults?

45º with a firm end feel.

What is the typical ROM for thoracolumbar lateral flexion in adults?

35º with a firm end feel.

What vital signs should be monitored in clinical settings?

Pulse rate, blood pressure (BP), and respiratory rate (RR).

What is the importance of monitoring vital signs?

To assess the physiological responses to activity or stress and identify signs of physiologic stress.

How should blood pressure be measured?

In different positions to assess changes in response to activity or posture.

What methods can be used for subjective measurement of pain level?

Various scales and documentation methods to properly record findings.

What is passive insufficiency?

A condition where two joint and multi-joint muscles do not allow full ROM across all the joints they cross.

What factors may affect flexibility in individuals?

Age, sex, body habitus, and activity levels.

What is the purpose of taking vital signs?

To monitor a patient's physiological status, assess the body's response to stress, provide indications of overall health, determine response to therapeutic interventions, assist in clinical decision-making, and evaluate the need for referrals.

What are the key vital signs monitored?

Pulse rate, blood pressure (BP), and respiratory rate (RR).

What does pulse indicate in terms of cardiovascular health?

It is an indirect assessment of the cardiovascular system's ability to provide blood flow.

What is the normal range for resting heart rate (HR)?

60-100 beats per minute (bpm).

What does a resting heart rate greater than 85 bpm indicate?

It may indicate deconditioning.

Define bradycardia and tachycardia.

Bradycardia: HR < 60 bpm; Tachycardia: HR > 100 bpm.

What are the characteristics of pulse rhythm?

Regular, regularly irregular, and irregularly irregular.

How is pulse quality assessed?

Quality is assessed on a scale from 0 (absent) to 4+ (bounding).

Where can the femoral pulse be located?

In the femoral triangle, between the inguinal ligament, sartorius, and adductor magnus.

What is the normal respiratory rate for adults?

12-20 breaths per minute.