Potpourri
Components of this type of note are: Examination, Evaluation, Diagnosis, Prognosis, Plan of Care
What is Initial Evaluation/Examination?
Examples include: pain, decreased knee strength, decreased ROM, impaired posture.
What is body structures / function or impairments?
Acceptable ways to start a sentence in this section
What is “pt reports,” “pt complains of” or “pt states”
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?
Which prognosis should the PT typically NOT choose?
What is poor?
The words in the acronym “SOAP”
What are Subjective, Objective, Assessment and Plan?
Examples include: inability to walk without a device, difficulty bathing, dependent transfers
What are activity limitations?
When you ask a patient about their cardiovascular system, GI health, vision, etc.
What is Review of Systems?
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?”
Medical diagnosis or PT diagnosis?
s/p R TKA
What is medical diagnosis?
Where you describe the home set-up (stairs, etc).
Examples include: 10 stairs to enter, supportive caregiver, adjustable workstation
What are environmental factors?
The patient wants to accomplish these in PT
What are patient goals?
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.”
"Patient demonstrates good potential to achieve full independence with ADLs” is an example of what?
What is the prognosis?
Within how many hours should you have your documentation finished after you conclude treatment?
What is 24 hours?
Examples include: inability to attend school due to difficulty negotiating the stairs; inability to work; inability to perform community volunteer role.
What is participation restrictions?
The acronym used to obtain details about a patient’s symptoms.
What is OLDCARTS?
What is included when documenting PROM?
What is: the joint, the side, the range, and the end feel?
Pt. completes the TUG (timed up and go) in 16 seconds.
What would you write in the assessment?
What is: TUG score of 16 indicates moderate risk of falls.
How you sign a note as a student
What is SPT?
Examples include: motivation, values, and culture.
What are personal factors?
Describes the story of why the patient is in physical therapy at this time.
What is history of current condition / chief complaint?
What is included when documenting gait?
What is: type of surface, distance, level of assistance, assistive device, and gait deviations?
Write a statement for interpreting the following:
Quad strength: R 3+/5 L 5/5
Transfer: Pt. performs sit to stand w/ mod assist and blocking of R knee.
What is: Decreased R quad strength is limiting independence w/ sit to stand?