Potpourri
ICF
Subjective
Objective
Objective
100
Components of this type of note are: Examination, Evaluation, Diagnosis, Prognosis, Plan of Care
What is Initial Evaluation/Examination?
100
Abnormalities in body structure or function
What are impairments?
100
Acceptable ways to start a sentence in this section
What is “pt reports,” “pt complains of” or “pt states”
100
Document:
The patient is able to bend his right knee to 85 degrees, starting from straight
What is:
R knee AROM 0-85 degrees
Or
AROM R knee 0-85⁰?
100
Document: The patient complained of 8/10 pain in his right knee while trying to stand up from the chair.
What is “Pt. attempted STS from chair and was unable 2⁰ 8/10 R knee pain?”
200
The words in the acronym “SOAP”
What are Subjective, Objective, Assessment and Plan?
200
Examples include: inability to walk without a device, difficulty bathing, needing assistance with transfers
What are activity limitations?
200
When you ask a patient about their cardiovascular system, GI health, vision, etc.
What is Review of Systems?
200
Document:
The patient is able to safely move from the bed to the chair without any help.
What is
“Pt. transfers bed to chair I or Bed to chair transfer w/ I?”
200
Document: The patient and therapist walked 75 feet in hallway one time with the therapist providing min assist to help the patient maintain her balance because of dizziness. Pt. used front wheeled walker.
What is: Pt. amb. 75’ on level surface, FWW, min A x1 for balance?
300
Where you describe the home set-up (stairs, etc).
What is subjective and living environment?
300
Decreased strength in B quadriceps and decreased knee range of motion
What is body structure and function (impairments)?
300
The patient wants to accomplish these in PT
What are patient goals?
300
Document:
Your patient walks with a limp and keeps his knee straight on his right side due to pain
What is “Pt. amb with antalgic gait and decreased R knee flexion? Or Pt. amb w/ R antalgic gait, decreased R knee flexion during heel off and swing phases.”
300
Document: PT helped patient a little bit while walking outside on the grass for 5 minutes with no assistive device.
What is Pt. amb. X 5 min. w/ min A x1 on uneven grassy surface.
400
Within how many hours should you have your documentation finished after you conclude treatment?
What is 24 hours?
400
Category where you would put the info about a high school student being unable to attend class due to difficulty negotiating the stairs.
What is participation restriction?
400
The acronym you learned to obtain details about a patient’s symptoms
What is OLDCARTS?
400
What is included when documenting PROM.
What is: the side, the range, and the end feel?
400
Document: Patient is able to move right shoulder into 180 degrees of flexion and left shoulder into 90 degrees of flexion. Right shoulder moves into 180 degrees abduction, while left still needs 20 degrees to go through the full range. The PT is able to move the patient’s left arm into 180 degrees flexion and abduction, with soft end feel.
500
How you sign a note as a student
What is SPT?
500
Examples include: motivation, values and culture
What are personal factors?
500
This part of the subjective describes the story of why the patient is in physical therapy at this time
What is history of current condition / chief complaint?
500
Document:
A patient cannot get to the end range of knee flexion because of pain. What word would you use to document the end feel?
empty
500
Document: hip flexors 4/5 RLE and 3/5 LLE. Quads RLE 4/5, 3/5 LLE. Both gluts 5/5.
R L
Hip flexors 4 3
Quads 4 4
Gluts 5 5