Information Gathering in Physiotherapy – Lecture Vocabulary

Information Gathering in Physiotherapy

Overview of Information Gathering

• Importance of gathering information about patients to assist in health care decisions.

• Split into two sections: subjective assessment (this week) and physical assessment (next week).

ICF Framework (International Classification of Functioning)

• A useful framework for gathering comprehensive information about patients.

• Historically focused on health conditions, anatomy, and physiology but now includes personal and environmental/contextual factors.

Components of the ICF Framework

1. Health Condition: the primary focus traditionally for health care professionals.

2. Body Functions and Structures: physiological and anatomical aspects.

3. Personal Factors: include age, sex, gender, race, culture, family dynamics, etc.

4. Environmental Factors: involve home/work environment, social interactions, and broader societal impacts (e.g., climate change).

   • Importance: Recognize how these factors affect a patient’s health and care.

   • Example: Hot weather could exacerbate conditions like MS, leading to changes in patient lifestyle and safety.

5. Activity Limitations and Participation Restrictions:

   • Activity Limitations: Specific tasks a patient struggles with (e.g., bending knee, sitting).

   • Participation: Broader activities affected by these limitations (e.g., inability to sit at work or play sports).

6. Biopsychosocial Model: Incorporates biological, psychological, and social factors affecting a patient's health.

Subjective Assessment

• Information received from various sources:

  • Patient's account, previous documentation, and test results.

• SOAP Notes: Structure for documenting patient assessments:

  1. Subjective: Information provided by the patient.

  2. Objective: Physical assessments conducted by the physiotherapist (e.g., assessments of strength, posture, movements).

  3. Assessment: Diagnosis or professional interpretation based on subjective and objective data.

  4. Plan: Outline of recommended treatment moving forward.

• Recognize different between medical model and physiotherapy management, emphasizing treatment in sessions rather than just planning.

Importance of Comprehensive Assessment

• Engage with patients and maintain a holistic view of their individual circumstances and concerns.

• Encourage follow-up questions during treatments in various environments (clinical, hospital, or private practice).

• Avoid exploitation of checklists without meaningful engagement with the patient.

Gathering Information Prior to Patient Interaction

• Be aware of any information available before the patient arrives (e.g., notes, letters from GPs).

• Understand that a lot of the initial information may not be available in private practice contexts.

• Importance of establishing rapport and gathering additional patient histories while respecting their experiences and perspectives.

Engaging with Patient History

1. Present and Past History: Key points to consider while assessing:

   • How long symptoms have been present, any triggering events, and prior treatments.

2. Family History: Influence of genetics and past experiences on current conditions.

3. Social History: Impact of personal environment on health conditions, addressing support systems and participation capabilities.

Goals and Expectations

• Establish patient expectations around discharge or endpoint of therapy, ensuring goals are realistic according to their circumstances.

• Ensure that potential psychological factors are recognized which might influence symptom severity and recovery.

Assessments and Screening Tools

• Use of formal assessments for specific conditions (like anxiety or disability).
  - Reiterating the importance of understanding the validity (accuracy) and reliability (repeatability) of such tools in practice.

Conclusion

• The efficacy of physiotherapy hinges on comprehensive knowledge of patient backgrounds to manage assessments effectively and develop appropriate treatment plans.