Information Gathering in Physiotherapy – Lecture Vocabulary

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).

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.

Health Condition: the primary focus traditionally for health care professionals.
Body Functions and Structures: physiological and anatomical aspects.
Personal Factors: include age, sex, gender, race, culture, family dynamics, etc.
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.
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).
Biopsychosocial Model: Incorporates biological, psychological, and social factors affecting a patient's health.

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.

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.

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.

Present and Past History: Key points to consider while assessing:
- How long symptoms have been present, any triggering events, and prior treatments.
Family History: Influence of genetics and past experiences on current conditions.
Social History: Impact of personal environment on health conditions, addressing support systems and participation capabilities.

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.

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.

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