ꑑꑀꅂ꽦뻺껦ꚡ뭐뵤ꖻ - pt.ntu.edu.t · pdf file44 ꑑꑀꅂ꽦뻺껦ꚡ뭐뵤ꖻ...

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十一、病歷格式與範本

神經疾患相關病歷格式與範本（1）中樞系統損傷評估（2）脊髓損傷評估範例一：腦中風初評範例二：腦中風結案小兒疾患相關病歷格式與範本（1）兒童物理治療評估報告（2）病房兒童物理治療（3）新生兒評估（4）中文版新生兒神經行為評估量表

範例一：一般發展遲緩（含 IPP）範例二：腦性麻痺（含 IPP）範例三：新生兒範例四：病房兒童物理治療

骨科疾患相關病歷格式與範本（1）肌肉骨骼疾患評估（2）Physical Therapy for Shoulder joint

（3）Physical Therapy Assessment for Low Back Pain （4）Physical Therapy Assessment for Cervical Syndrome (5) 病房骨科物理治療評估

範例一：肩部疾患心肺疾患相關病歷格式與範本

(1) 胸腔疾患評估

(2) 呼吸循環物理治療每日紀錄

(3) 復健部物理治療心肺疾病運動訓練病患狀況紀錄表

(4) 復健部冠狀動脈手術臨床路徑物理治療計畫表

(5) 復健部心房/心室中膈缺損手術(年齡大於 10歲)臨床路徑物理治療計畫表

範例一：CABG I

範例二：CABGⅡ 範例三：Lung Resection 範例四：Cardiac Rehabiltation 範例五：COPD

45

神經疾患相關病歷格式與範本

（1）中樞系統損傷評估國立台灣大學醫學院附設醫院

復健部物理治療報告單(中樞神經系統損傷評估) 病歷號姓名床號第頁

I. Basic Data:

Diagnosis:

Age: y/o Sex: Height:_____ cm Weight: _____kg

Home environment:

Tel: PT begins on:

□ Initial Note □ Acceptance Note □ Summary Note □ Discharge Note

II. Brief History and Lab Results:

III. Physical Examinations:

Consciousness:

Mentality: Judgment Orientation Memory Abstract thinking Calculation

Communication: Vision: homonymous hemianopia: L R － neglect: L R －

Facial palsy: L R － / mild moderate severe / central peripheral

Muscle tone:

ROM / pain / Subluxation:

Brunnstrom stage RUE-P: RUE-D: RLE: ( I ~ VI ) LUE-P: LUE-D: LLE:

Muscle strength: RUE: P/D- RLE: P/D- LUE: P/D- LLE: P/D-

Sensation: Light touch □RUE-P _____ □RUE-D _____ □RLE _____ (1=intact, □LUE-P _____ □LUE-D _____ □LLE _____ 2=impaired, Proprioception □RUE-P _____ □RUE-D _____ □RLE _____ 3=absent) □LUE-P _____ □LUE-D _____ □LLE _____

Coordination: normal impaired N/T FNF test : L____sec R____sec(5 repetitions) HKH test : L____sec R____sec(5 repetitions) tremor : － intentional resting RUE RLE LUE LLE dysdiadokokinesia － RUE RLE LUE LLE dysmetria － RUE RLE LUE LLE

neurological level / miscellaneous:

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Functional status:(key: Independent, Supervision, close guard, contact guard, minimal, moderate, maximal, Assistance, verbal cueing example: min A of 1 plus mod verbal cueing)

rolling: R: L: supine ←→ sit:

sit ←→ stand:

chair ←→ bed:

sitting balance: static: □Poor □Fair □Good dynamic: □Poor □Fair □Good supported: + － ; sec lean to R L －, lose balance to ________________side

standing balance: static: □Poor □Fair □Good dynamic: □Poor □Fair □Good

device (support): Romberg: ＋－ , EO sec, EC sec; feet apart cm

One leg stance: lean to R L － , lose balance to side

ambulation: cadence: step/min Motor Assessment Scale: speed: m/min W/C activity: assistance: endurance: pattern:

ramp: stairs: obstacles: squatting: IV. Major Problems:

V. Goal: short term (in 2 weeks) long term (at D/C) VI. PT Treatment Programs: VII. Home Program:

Therapist(s):____________

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（2）脊髓損傷評估病歷號姓名床號第頁

I. Basic Data: Date: 20 / / Diagnosis________________________________________________________

Birthday: 19 / / ( y/o) Sex M / F Height cm Weight kg Home environment F with/without elevator Tel PT begins on 20 / / II. Brief History and Lab Results: III. Physical Examinations:

1. Consciousness: 2. Mentality: Judgment Orientation Memory Abstract thinking Calculation 3. Muscle tone: 4. ROM/Pain/Subluxation: 5. Functional Status(key: Independent, Supervision, minimal, moderate, maximal,

Assistance. Example: min A of 1 plus mod verbal cueing) rolling: R L supine sit: sit stand: chair bed: sitting balance: static: Poor Fair Good; dynamic: Poor Fair Good, supported:+－, sec lean to R L －, loss balance to side standing balance: static: Poor Fair Good; dynamic: Poor Fair Good, device(support): (EO: eyes open; Romberg: ＋－, EO sec, EC sec; feet apart cm (EC: eyes closed) One leg stance: R/L: EO / sec, EC / sec Ambulation: cadence: step/min Motor Assessment Scale: speed: cm/sec W/C activity:

assistance: endurance: ramp: stairs: obstacles: squatting: IV. Complications:

Musculoskeletal condition: Pressure sore Contracture/fracture Respiratory condition: Paradoxical breathing: ＋－;

Cough ability: Functional , Weak functional , Non-functional Cardiovascular condition: Postural hypotension:＋－; Autonomic dysreflexia: ＋－

Muscle strength: Gluteus med(L4-S1): (R) (L) , Gluteus max(L5-S8): (R) (L) , Abdominal muscles(T6-T12) : (R) (L) , Hamstring(L5-S2) : (R) (L) .

Initial Summary Acceptance Discharge

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病歷號姓名床號第頁 V. Standards for Neurological Classification of Spinal Cord Injury

Motor R’t L’t Sensory Light touch Pin prick

C5 Elbow flexors C2 – S4, 5 Right Left Right Left C6 Wrist extensors C7 Elbow extensors

segments

C8 finger flexors

2 = normal

subtotal T1 Finger abductors

L2 Hip flexors segments

L3 Knee extensors

1 = impaired

subtotal L4 Ankle dorsiflexors L5 Long toe extensors

segments

S1 Ankle plantar flexors

0 = absent

subtotal Total Total Motor score Sensory score Motor level Sensory level Neurological level Voluntary anal contraction ASIA Impairment Scale Any anal sensation Zone of partial preservation Bullbocavernoses reflex

Date: 20 / /

VI. Functional Assessment of Activities (Barthel Index)

Independent Dependent Independent Dependent

assistive device assistive device

Items

Without With

with

some

help

with

maximun

help

Items

Without With

with some help with

maximun

help

1. Feeding □10 □5 □0 6. Bladder □10 □5 (occasional

accident)

□0

2.Dressing □10 □5 □0 7. Bowels □10 □5 □0 3. Personal

hygiene

□05 □0 8. Transfer

(chair &

bed)

□ □10 (with min help

or guide)

□5 □0

4. Bathing □05 □0 9.

Ambulation

□15 □10 (Walking with

help)

□5

(indep. With W/C,

if unable to walk)

□0

5. Toliet □10 □5 □0 10. Up/down

stairs

□10 □5 □0

Total score:

VII. Major Problems: VIII. Goals: Short term(in 2 weeks)

Long term(at D/C)

IX. PT treatment programs: Therapist(s):

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範例一：腦中風初評國立台灣大學醫學院附設醫院

復健部物理治療報告單(中樞神經系統損傷評估) 病歷號 0839821 姓名李×× 床號 15A10-1 第 1 頁

I. Basic Data: Date: 92-2-19 Diagnosis R’t cerebellar infarction c R’t hemiparesis Age 59 y/o Sex M Height 170 cm Weight 68 kg Home environment 4F s elevator Tel PT begins on 92-2-19

II. Brief History and Lab results: This 59 y/o male has history of CVA or suspected TIA in 90-7 with sequelae of movement. On 92-2-9, vertigo, headache, vomiting attacked while doing SPA bathing. So he was sent to our ER where nystagmus to R’t, R’t limb ataxia & R’t dysmetria was found. CT showed a hypodense lesion at R’t cerebellar sphere. Medication was given. Until the patient’s neurological condition was stable, PT was consulted for further rehab. III. Physical Examination: Consciousness: clear mentality: judgment intact Orientation intact Memory intact Abstract thinking intact Calculation intact Communication: intact, but L’t ear is nearly deaf due to COM since 20+ yrs ago vision: diplopia (+) when looking at mirror homonymous hemianopia: L R － (L: left, R: right) since last CVA or TIA neglect: L R －

facial palsy: L R － / mild mod severe / central peripheral muscle tone: WNL

ROM/pain/ subluxation： WNL / －/－

Brunnstrom Stage: RUE-P VI RUE-D VI RLE VI LUE-P VII LUE-D VII LLE VII muscle strength: RUE: normal RLE normal LUE: normal LLE normal sensation: Light touch (1= intact, RUE-P 1 RUE-D 1 RLE 1 2= impaired, LUE-P 1 LUE-D 1 LLE 1 3= absent) Proprioception RUE-P 1 RUE-D 1 RLE 1 LUE-P 1 LUE-D 1 LLE 1 coordination: normal impaired N/T (not tested) FNF test: L 8 R 10 sec/5 repetitions HKH test: L 5 R 5 sec/5 repetitions tremor: － intentional resting LUE LLE RUE RLE dysdiadokokinesia: － LUE LLE RUE RLE dysmetria: － LUE LLE RUE RLE Neurological level/Miscellaneous

(1) HTN(+) 5 yrs c regular medical control. (2) hyperlipidemia (+) 2 yrs under f/u. (3) old CVA or suspected TIA in 90-7 when CT showed multiple lacunar infarction. (4) COPD(+). (5) L’t T-M j’t fx in 90-7 due to trauma (fell down when CVA or TIA attacked.)


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國立台灣大學醫學院附設醫院


Functional Status (key: Independent, Supervision, minimal, moderate, maximal, Assistance. example: min A of 1 plus mod verbal cueing) rolling: R I L I supine ←→ sit: I sit ←→ stand: self- supporting on walker c contact guard chair ←→ bed: c walker & contact guard sitting balance: static: Poor Fair Good; dynamic: Poor Fair Good supported: ＋－, ≧120 sec lean to R L －, lose balance to － side standing balance: static: Poor Fair Good; dynamic: Poor Fair Good device(support): none (EO: eyes open; Romberg: ＋－, EO ≧60 EC ≧60 sec; feet apart 0 cm EC: eyes closed) NA One leg stance: R: EO sec; EC sec ( trunk sway↑both when L: EO sec; EC sec EO or EC) mild Lean to R L －, lose balance to R’t side ambulation: cadence: NT step/min Motor Assessment Scale: 3 speed: NT cm/sec W/C activity: I assistance: c walker & minA endurance: ≧5 m

pattern: ataxic gait: unwell control of RLE, wide base, easy to lose balance when turning, R’t step length ﹥L’t

ramp: NA stairs: NA obstacles: NA squatting: NA IV. Major Problems: 1. Impaired coordination of R’t limbs 2. Poor bed mobility and transfer skills 3. Insufficient standing balance 4. Unable to walk s device or up/down stairs 5. Insufficient exercise endurance V. Goal: short term ( in 2 weeks) 1. Improve coordination of R’t limbs 2. Transfer safely 3. Up/down stairs c self-supporting on rail long term (at D/C): 1. Ambulation without device under supervision in outdoor 2. Nearly normal gait pattern VI. PT treatment programs:

1. Coordination training ( Frenkel’s ex’) 2. Bed mobility training and counseling for transfer skills 3. Balance training 4. Ambulation training and gait correction 5. Endurance training

VII. Home programs:

1. Rhythmic, reciprocal, direction- alternating AROM ex’ of bilateral limbs 2. Walking ex’ Therapist(s): (簽章)

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範例二：腦中風結案



I. Basic Data: Date: 92-2-26 Diagnosis R’t cerebellar infarction c R’t hemiparesis Age 59 y/o Sex M Height 170 cm Weight 68 kg Home environment 4F s elevator Tel PT begins on 92-2-19

II. Brief History and Lab results: This 59 y/o male is a case of recurrent CVA on 90-7 & 92-2-9. PT started on 92-2-19. After 4 times of PT treatments, the p’t has improvements in ambulatory ability & coordination of R’t limbs, and PT DC goals were generally met. The p’t will be discharged from our H on 92-2-27, so PT discontinued on 92-2-26. III. Physical Examination: Consciousness: clear

mentality: judgment intact Orientation intact Memory intact Abstract thinking intact Calculation intact

Communication: intact, but L’t ear is nearly deaf due to COM since 20+ yrs ago

vision: diplopia (+) when looking at mirror homonymous hemianopia: L R － (L: left, R: right) since last CVA or TIA neglect: L R － facial palsy: L R － / mild mod severe / central peripheral

muscle tone: WNL

ROM/pain/ subluxation: WNL / － /－

Brunnstrom Stage: RUE-P VI RUE-D VI RLE VI LUE-P VII LUE-D VII LLE VII

muscle strength: RUE: normal RLE normal

LUE: normal LLE normal

sensation: Light touch (1= intact, RUE-P 1 RUE-D 1 RLE 1 2= impaired, LUE-P 1 LUE-D 1 LLE 1 3= absent) Proprioception RUE-P 1 RUE-D 1 RLE 1 LUE-P 1 LUE-D 1 LLE 1

coordination: normal impaired N/T (not tested) FNF test: L 6 R 7 sec/5 repetitions HKH test: L 5 R 5 sec/5 repetitions tremor: － intentional resting LUE LLE RUE RLE dysdiadokokinesia: － LUE LLE RUE RLE but improved dysmetria: － LUE LLE RUE RLE but improved

Neurological level/Miscellaneous (1) HTN with regular medical control. (2) hyperlipidemia (+) 2 yrs under f/u. (3) old CVA or suspected

TIA in 90-7 when CT showed multiple lacunar infarction. (4) COPD. (5) L’t T-M j’t fx in 90-7 due to trauma (fell down when CVA or TIA attacked.)


52



Functional Status (key: Independent, Supervision, minimal, moderate, maximal, Assistance. example: min A of 1 plus mod verbal cueing) rolling: R I L I supine ←→ sit: I

sit ←→ stand: S chair ←→ bed: S

sitting balance: static: Poor Fair Good; dynamic: Poor Fair Good supported: ＋－, ≧120 sec lean to R L －, lose balance to － side standing balance: static: Poor Fair Good; dynamic: Poor Fair Good device(support): none (EO: eyes open; Romberg: ＋－, EO ≧60 EC ≧60 sec; feet apart 0 cm EC: eyes closed) One leg stance: R: EO 5 sec; EC 0 sec L: EO 7 sec; EC 0 sec Lean to R L －, lose balance to － side ambulation: cadence: NT step/min Motor Assessment Scale: 4 speed: NT cm/sec W/C activity: I assistance: under S endurance: ≧10 mins on treadmill ( 1 mph)

pattern: nearly normal gait pattern, but sometimes loses balance esp. when turning to R’t

ramp: NT stairs: ＋ step over step, hand on rail c contact guard

obstacles: ＋ squatting: ＋

IV. Major Problems: 1. still mild dysmetria & disdiadokokinesia of R’t limbs 2. insufficient one leg standing ability 3. insufficient dynamic balance of ambulation V. Goal: short term ( in 2 weeks)

long term (at D/C): The initial PT DC goals were met. Suggest the p’t to keep PT training at OPD to correct the remained problems.VI. PT treatment programs:

VII. Home programs: 2~3 times a day 1. tandem standing

2. one- leg standing 3.用雙手或右腳打節拍

4. stationary bicycle up to 20~30 mins/ bout, 3 bouts/ wk Therapist(s): (簽章)

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國立台灣大學醫學院附設醫院病歷號 xxxxxxx 姓名 x×× 床號 xxxxx 第 1 頁

病房物理治療每日記錄（神經系統）

Bedside Physical Therapy Daily Note（Neurological Conditions） Date 95-4-20

Phsical Examination Consciousness E4M6V5 Mentality intact Hemianopsia/neglect L’t/－ Comprehension/expression ＋/＋ Muscle tone:RUE/RLE 0/0 Muscle tone:LUE/LLE F 1/E 1 Brunnstrom stage: L UE-P/D Ⅲ／Ⅰ Brunnstrom stage: L LE Ⅴ ROM/pain/subluxation WNL/-/- Coordination intact Functional Status Rolling to R’t /L’t I/I Supine to sit minA Sit to supine minA Chair to bed S Sit to stand I Static/dynamic sitting balance G/G Static/dynamic standing balance G/F Ambulation:device/assistance －/minA Endurance 50 m Up/down stairs NT Treatment Programs 1. Caregiver education ˇ 2. Cognition training 3. Sensation organization training 4. Facilitation ˇ 5. ROM exercise 6. Coordination training 7. Muscle strengthening ˇ 8. Bed mobility training 9. Transfer training 10. Sitting balance training 11. Standing balance training 12. Ambulation training ˇ 13. Up/ down stairs training 14. Electrical stimulation ˇ 15. Gait correction 16. Endurance training

Sign SPT、、、

Muscle tone: Flexor: F, Extensor: E, MAS 0, 1, 2, 3, 4, 5. eg. F1; Balance: Poor, Fair, Good Functional status: Dependent, max.A, mod.A, min.A, contact guard, close guard, Supervision, Independent

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小兒疾患相關病歷格式與範本

（1）兒童物理治療評估報告


病歷號 XXXXXXX 姓名 XXX 床號 OPD 第 1 頁

兒童物理治療評估報告

診斷/併發症：評估日期：性別：生日：年齡：電話：地址：注意事項：轉介醫師：

治療起始時間：物理治療：職能治療：語言治療：心理治療：出生史：懷孕週數：出生序：出生體重(%)：其它：目前體重(kg / %)：目前身高(cm / %)：目前頭圍(cm / %)：可能造成發展障礙原因：相關檢查結果（x光，腦波，血液檢查等）：疾病史：治療史（含相關各科及早期療育）：目前是否使用藥物：□ 否，□ 是；藥物名稱及作用：達成發展基石之年齡 (月)：

頭部控制翻身獨坐貼地爬離地爬行走(5步) 說話(5個單字) 家屬的期待：

評估：

1. 環境障礙和整合： 2. 輔具需求與使用： 3. 家中或社區活動(課內外活動)執行與參與： 4. 動作控制、協調與學習(包含功能性行走能力、姿勢控制與轉/移位能力等)： 5. 警覺性、注意力、認知、行為：

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病歷號姓名床號第 2 頁

兒童物理治療評估報告

6. 體適能(包含身體組成、心肺耐力、肌力與肌耐力、柔軟度等)：

7. 身體機能構造(包含關節角度、關節與姿勢變形、感覺知覺、肌張力等)：

8. 其他(如發展評估、職前評估)：

9.相關福利服務（殘障手冊、發展遲緩證明等）：不需已具備需要 10.個案及家庭優勢：

主要問題：

治療目標：

長期目標（至年月日）：

短期目標（至年月日）：

治療計畫：

居家訓練計畫：

治療師簽章：

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（2）病房兒童物理治療


復健部物理治療報告單（病房兒童物理治療病歷記錄）

病歷號姓名床號第頁

Physical Therapy Note for Bedside Pediatric Patients Initial Note Acceptance Note Summary Note Discharge Note

I. Basic Data Sex: Age: (Birth Date: ) Date: Date of Admission: Date of Onset: Impression: Medical Findings:(CT,EEG.....etc) Other Medical Problems: Reasons for Consulting PT: Date of PT Starting: Brief History

II. Physical Examination Consciousness/Mentality:

Cooperation/Motivation of the Child/Parents:

Vision/Hearing:

Communication/Feeding:

Cardiopulmonary Function: Sensation: Muscle Tone: ROM: MMT: Developmental Status: (evaluation tool: )

57



病歷號姓名床號第頁 Functional Status: Others: III. Major Problems: IV. Physical Therapy Goals: STG: LTG: V. PT Programs: VI. Home Programs: SPT Sign: / PT Sign:

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（3）新生兒評估國立台灣大學醫學院附設醫院

復健部物理治療報告單（新生兒評估）病歷號姓名床號第頁

Physical Therapy Note for Newborn Baby Date

Initial Note Acceptance Note Summary Note Discharge Note I. Basic Data Sex Date of Birth Gestational Age Birth Body Weight Body Length Head Girth Apgar Score at 1 min at 5 min Birth History: Impression Date of Admission Medical Finding (CT, Brain echo, EEG, EKG……ect.): Other Medical Problems: Maternal History: Other Medical Problems: Nil. Mother’s name education occupation Father’s name education occupation Date of PT Start II. Brief History III. Physical Examination 1. Vital Sign (HR, RR, SaO2): 2. Range of Motion:

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復健部物理治療報告單（新生兒評估）病歷號姓名床號第頁

3. Sensation: 4. Breathing Condition: a. Breathing Sound: b. Breathing Pattern: 5. Neonatal Neurobehavioral Examination (NNE)(See the special sheet): Conceptional Age Total Score a. Tone and Motor Pattern (Section score: ) b. Primitive Reflex (Section score: ) c. Behavior Responses (Section score: ) 6. MMT: 7. Muscle Tone: 8. Oral Function: IV. Major Problem V. PT Goal VI. PT Program SPT Sign: / PT Sign:

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（4）中文版新生兒神經行為評估量表

62

範例一：一般發展遲緩基本資料：姓名：唐 XX 診斷：發展遲緩（染色體異常：de Lange syndrome）性別：女出生日期：2001.03.25 懷孕周數：39週胎次：G1P1 出生體重(%)：1560克(＜10%) 目前體重：5.3公斤(＜3%) 出生身高(%)：40公分(＜10%) 目前身高：63公分(＜3%) 出生頭圍(%)：27公分(＜10%) 目前頭圍：38公分(＜3%) 危險因子：產前：染色體異常（de Lange syndrome）簡要病史：個案出生後由於其特殊臉部特徵，經染色體檢查確定為狄蘭氏症，並且自 5個月大開始至台大醫院接受門診小兒物理治療。發展史：評估工具（EIDP）＊粗動作發展

評估日期發展年齡發展商數具備能力 2001.08.30 (5+M) 3-5M 60%-100% 1.趴著可將頭抬高 90度

2.扶站時雙腳可輕微承重 2002.01.08 (9+M) 6-8M 65%-90% 1.趴著可肚子貼地打轉，但尚不會爬

2.可自己手撐地坐 1-2分鐘，扶站時會主動跨步

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9 10

生理年齡 (月)

發展年齡 (月)

63

＊精細動作發展

評估日期發展年齡發展商數具備能力 2001.08.30 (5+M) 3-5M 60%-100% 1.眼睛可追視 30公分遠物體

2.雙手會在身體中線玩 2002.01.08 (9+M) 6-8M 65%-90% 1.可看到 2-3公尺遠物體，但追視速度慢

2.可將玩具由一手換至另一手 3.可用耙的方式抓起小餅乾

＊認知發展

評估日期發展年齡發展商數具備能力 2001.08.30 (5+M) 4-5M 80%-100% 1.會有反覆性的行為，如搖動鈴鐺

2.當注視的物體掉下時，會看著物體消失的地方

2002.01.08 (9+M) 6-8M 65%-90% 1.可找到部分藏起的物體 2.會把蓋在臉上的毛巾扯掉

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9 10

生理年齡 (月)

發展年齡 (月)

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9 10

生理年齡 (月)

發展年齡 (月)

64

＊語言發展

評估日期發展年齡發展商數具備能力 2001.08.30 (5+M) 3-5M 60%-100% 1.會主動發出聲音

2.會隨情緒不同發出不同聲音 2002.01.08 (9+M) 6-8M 65%-90% 1.會以不同哭聲表示不同需求

2.會發出雙音節聲音，如 ba-ba，ma-ma ＊社會人際發展

評估日期發展年齡發展商數具備能力 2001.08.30 (5+M) 3-5M 60%-100% 1.自己一個人時會哭或不高興

2.會分辨熟人與陌生人 2002.01.08 (9+M) 6-8M 65%-90% 1.陌生人抱時會哭

2.大人拿走其正在玩的玩具時會不高興

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9 10

生理年齡 (月)

發展年齡 (月)

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9 10

生理年齡 (月)

發展年齡 (月)

65

生活自理發展

評估日期發展年齡發展商數具備能力 2001.08.30 (5+M) 3-5M 60%-100% 1.喝奶時吸吞協調控制良好 2002.01.08 (9+M) 9-11M 100%-120% 1.可自己拿著餅乾吃

2.會自己拿著奶瓶吸奶，但食量少 3.可用湯匙餵食稀飯、麥糊等半固體食品，食量少

＊骨骼肌肉方面評估日期主要問題 2001.08.30 (5+M) 雖為低張力，但有下列問題：

1.兩邊髖內收肌（hip adductor）較緊，使得個案較習慣長坐（long sitting），不喜歡盤腿坐（ring sitting）

2.兩邊大拇指屈肌較緊，造成大拇指多在手掌內（thumb in palm），大拇指主動動作也較少

3.肌力略低，但可抗地心引力 2002.01.08 (9+M) 各個關節活動度均正常，但雙手主動動作仍較少

＊其他：

1.神經肌肉系統：低張力 2.心肺系統：耐力略低

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9 10

生理年齡 (月)

發展年齡 (月)

66

國立臺灣大學醫學院附設醫院

病歷號 1234567 姓名唐 XX 床號 OPD 第 1 頁

兒童物理治療評估報告診斷/併發症：發展遲緩（染色體異常：de Lange syndrome）評估日期： 2002.01.08 性別：女生日： 2001.03.25 年齡： 9+M 電話：（02）2333-3333 地址：台北市中正區 XX路 X 號注意事項：無轉介醫師： Dr. Lu

治療起始時間：物理治療： 2001.08.30 職能治療：（--）語言治療：（--）心理治療：（--）出生史：懷孕週數： 39周出生序： G1P1 出生體重(%)： 1560gm(＜10%) 其它：目前體重(kg / %)：5.3kg(＜3%) 目前身高(cm / %)：63cm(＜3%) 目前頭圍(cm / %)：38cm(＜3%) 可能造成發展障礙原因：產前：染色體異常（de Lange syndrome）相關檢查結果（x光，腦波，血液檢查等）：brain echo: normal；heart echo: small PFO but no heart

murmur；ABR(2002.6): L’t:25dB,R’t:35dB 疾病史：無其他疾病史治療史（含相關各科及早期療育）：目前在台大接受一週一次小兒物理治療，之前未接受過療育目前是否使用藥物：V 否， □ 是；藥物名稱及作用：達成發展基石之年齡 (月)：頭部控制 4M 翻身 6+M 獨坐（--）貼地爬（--）離地爬（--）行走(5步) （--）說話(5個單字) （--）家屬的期待：媽媽希望個案能有在家中獨自玩的能力，並希望她的發展能盡量趕上同齡孩童，

同時擔心孩子食量少的問題評估： 1. 環境障礙和整合：個案在家中多在小床或客廳的軟墊上活動，活動範圍及安全均符合個案目前需要，並且無明顯環境障礙。個案與爸媽、外公外婆、舅舅同住，主要照顧者為媽媽；家人對個案均非常疼愛並能給予媽媽足夠支持，每次治療時外婆會與媽媽一同出席。

2. 輔具需求與使用：個案在家中有一般幼兒餵食椅，但對個案而言太大；所以已建議媽媽在其身後加墊毛巾至腰部高度以維持良好坐姿。外出時則使用嬰兒推車。

3. 家中或社區活動(課內外活動)執行與參與：個案大致作息與一般嬰幼兒相同，但由於個案仍不會爬，所以家中移動仍需大人攜抱。每 4小時喝 90cc牛奶，但每餐需 30分鐘；吃副食品時會坐在餵食椅上進食，每次可吃約 1/3碗。平時則多在小床或客廳的軟墊上活動，會翻身自己拿到想要的玩具。請參考附件之日常生活作習表。

4. 動作控制、協調與學習(包含功能性行走能力、姿勢控制與轉/移位能力等)：個案平時多以翻身作功能性移動，仍不會爬。個案可在大人骨盆控制下由躺坐起，可用手撐地坐 1-2分鐘，但仍需大人協助才能坐著玩玩具。個案可被扶持站一會，雙腳並有主動跨步動作，可扶著腋下走 1-2公尺。

67


病歷號 1234567 姓名唐 XX 床號 OPD 第 2 頁

兒童物理治療評估報告 5. 警覺性、注意力、認知、行為：個案十分怕生，已可辨別陌生環境與陌生人；平日在家相當依賴媽媽，清醒時一定要媽媽在旁邊，無法自己一個人玩，容易哭泣。若媽媽在旁邊可與其他家人展現良好互動，會主動微笑，但還不太會玩互動遊戲（如躲貓貓）。

6. 體適能(包含身體組成、心肺耐力、肌力與肌耐力、柔軟度等)：個案活動耐力較差，趴著約玩 5-10分鐘即需要自己翻成正躺休息，四肢肌力均較一般同齡孩童差。

7. 身體機能構造(包含關節角度、關節與姿勢變形、感覺知覺、肌張力等)：個案全身張力較低，原來有髖關節內收肌及大拇指屈肌較緊的問題影響個案坐姿及手功能（據媽媽描述出生時就有），在教導媽媽簡單伸展運動後，目前這兩處關節活動度已正常。

8. 其他(如發展評估、職前評估)：發展評估（評估工具 EIDP）粗動作發展年齡 6-8M，發展商數約為 65-90%；精細動作發展年齡 6-8M，發展商數約為 65-90%；認知發展年齡 6-8M，發展商數約為 65-90%；語言發展年齡 6-8M，發展商數約為 65-90%；社會人際發展年齡 6-8M，發展商數約為 65-90%；生活自理發展年齡 9-11M，發展商數約為 100-120%。

9.相關福利服務（殘障手冊、發展遲緩證明等）：不需已具備 V 需要（已具備發展遲緩證明並通報台北市早療評估鑑定中心） 10.個案及家庭優勢：家長配合度佳，具良好居家訓練技巧；並能觀察孩子表現予以適當回應。主要問題：請參照以下所列個別化訓練計劃（IPP）

治療目標（至 2002年 04月 08日）：請參照以下所列個別化訓練計劃（IPP）

治療計畫：請參照以下所列個別化訓練計劃（IPP）

居家訓練計畫：請參照以下所列個別化訓練計劃（IPP）及所附之日常生活作習表

治療師簽章：潘懿玲

68

附件：

兒童一般日常生活作習表：

時間活動名稱與場所照顧者建議事項 9:00 9:30 10:00 PM 12:00 1:00 3:00 4:00 6:00 8:00 9:00 9:30 11:00

起床盥洗早餐（90cc, 30分鐘）

遊戲午餐（90cc, 30分鐘）

遊戲點心（果泥或其他副食品）午覺晚餐

洗澡、按摩喝奶（90cc, 30分鐘）遊戲就寢

媽媽媽媽媽媽媽媽媽媽媽媽媽媽媽媽媽媽媽媽爸爸或其

他家人

口腔動作刺激建議採坐姿餵奶建議採趴姿玩，同時進行姿勢

轉換、爬與站姿練習，並提供

6-8個月發展年齡合適之玩具建議採坐姿餵奶建議採趴姿玩，同時進行姿勢


6-8個月發展年齡合適之玩具建議坐在餵食椅內進食，鼓勵

發音，部分協助之進食建議採坐姿餵奶建議採坐姿餵奶建議採趴姿玩，同時進行姿勢


6-8個月發展年齡合適之玩具

其他說明

69

以粗動作活動為例之ICF模式分析 Health Condition Disorder/Disease

de Lange syndrome，發展遲緩 ↑

↓ ↓ ↓ Body Functions/Structure Activity Participation

神經肌肉系統：＊張力較低。

＊四肢肌力可抗地心引力較差，但較同齡兒童差。

＊趴時動態平衡及重心轉移能力差。

肌肉骨骼系統：＊兩邊髖內收肌較緊，但活動度在正常範圍內。

心肺系統：＊活動耐力較差。

認知能力發展輕度遲緩感覺系統：＊聽覺稍弱，但仍具功能。其餘無異常。

不會爬，趴時僅能維持 5-10分鐘。＊趴時手可伸直將身體撐起，但無法抬高一

手拿到玩具＊趴時雙腳有互踢動作。＊協助爬行時雙腳可互踢，但手未向前伸，

重心無法向前移，所以無法移動。

與同齡兒童相比，缺乏探索環境及

身體活動經驗；無法拿到較遠的玩

具。

Environmental

Factors Personal

Factors

＊在家中多在小床或客廳的軟墊上活動，範圍及安全均

符合個案目前需要，無明顯環境障礙。＊主要照顧者為媽媽；家人對個案均非常疼愛並能給予

媽媽足夠支持。

＊個案依賴媽媽給予刺激，無法自己一個人玩，主動

探索動機較低。

Barrier

Facilitor

70

個別化訓練計劃（IPP）日期：2002.01.08

主要問題：

I. 過度依賴母親，在家中幾乎都要媽媽抱，缺乏獨立活動機會。

II. 粗動作發展疑似遲緩：（目前發展年齡：6-8個月）

＊目前問題：

1.手撐地坐少於3分鐘，背部尚未挺直；且缺乏側邊及向後保護性伸直反應。

2.不會爬，雙手可將身體撐起且雙腳可互踢，但缺乏手向前伸的動作（尤其

右手）。

3.躺→坐時雙手會撐起身體，但需大人協助固定骨盆後才可坐起。

＊主要原因：

1.上肢主動動作控制不足

2.軀幹伸直肌與四肢肌力不足

III. 精細動作發展疑似遲緩：（目前發展年齡6-8個月）

＊目前問題：

1.不會一手各抓一積木。

2.尚未出現主動單一手指動作，會用耙的方式拿小餅乾並可送至嘴邊，但不會適時放手。

＊主要原因：

1.雙手主動動作少，手眼協調能力不足。

IV. 認知及語言發展疑似遲緩：（目前發展年齡6-8個月）

＊目前問題：

1.可看到2-3公尺遠的物體，但眼睛追視速度較同齡孩童慢，約需2秒/公尺的

速度才能跟得上。

2.找不到完全蓋住的物體，尚未建立物體恆久概念。

3.會主動發出ba-ba，ma-ma的聲音，但無主動模仿聲音及動作的行為。

＊主要原因：

1.物體記憶及眼睛追視能力不佳

V. 生活自理發展：

1.不喜歡牛奶味道，每餐進食量少（牛奶90cc）

71

長期目標：3個月（至2002.04.08）

I. 可自己玩超過10分鐘，只要媽媽偶爾出聲便可；媽媽偶爾能離開視線（如上廁所），回來

時不哭。

II. 粗動作：（目標發展年齡8-10個月）

1.獨立完成躺←→坐起，5/5成功；獨坐超過10分鐘，5/5成功。

2.肚子離地爬4 - 5步。

3.自行扶著傢俱站起，3/5成功；且扶傢俱站超過10分鐘不倒，可扶家具側移

4 - 5步。

4.牽兩手走超過3公尺，牽一手走5步。

III. 精細動作：（目標發展年齡8-10個月）

1.自己吃小餅乾（用拇指與食指指側拿小餅乾），5/5成功。

2.雙手各拿一個玩具可玩5分鐘不放手，4/5成功。

3.可觀察到單獨食指動作，1天可看到10次以上。

IV. 認知及語言：（目標發展年齡8-10個月）

1.大人在雙手中交換物品，以1秒交換1次的速度，眼睛能同步跟著追視，5/5

成功。

2.找到遮蓋在毛巾下的玩具，4/5成功。

3.可從盒子中拿出玩具，5/5成功；將玩具放入盒子，1/5成功。

4.模仿1 個常用的語言音，1/5成功；模仿1個常見的手勢，1/5成功。

V. 生活自理發展：

1.增加主食及副食品進食量，餵食時會想自己拿起湯匙

72

短期目標：

I.

長期目標：可自己玩超過10分鐘，只要媽媽偶爾出聲便可；媽媽偶爾能離開視線（如

上廁所），回來時不哭。

短期目標起訖日期訓練方式評量方式成果/日期備註

a.只要媽媽在旁

邊，可以自己玩

10分鐘不哭

2002.01.08

↓

2002.02.08

居家訓練：當孩子

自己玩得高興時，

媽媽試著不出聲讓

孩子自己玩。

直接觀察或

詢問家長

2002.02.08

80%

b.媽媽可離開一

分鐘不哭，可自

己玩超過5分

鐘，只要媽媽偶

爾出聲便可。

2002.02.09

↓

2002.03.08

同上，媽媽與其玩

躲貓貓遊戲，當媽

媽離開回來時可輕

聲稱讚孩子。

直接觀察或

詢問家長

2002.03.08

80%

有時可超

過10分鐘

不哭，有

時不行。

c. 媽媽可離開5

分鐘不哭，可自

己玩超過10分

鐘，只要媽媽偶

爾出聲便可。

2002.03.09

↓

2002.04.08

同上，當媽媽離開

回來時可輕聲稱讚

孩子。

直接觀察或

詢問家長

2002.04.08

50%

有時可超

過10分鐘

不哭，有

時不行。

但在治療

室時有時

可離開媽

媽接受治

療。

II. 粗動作：（目標發展年齡8-10個月）

長期目標：1.獨立完成躺←→坐起，5/5成功；獨坐超過10分鐘，5/5成功。


1a. 給予骨盆控

制下完成躺←→

坐起，3/5成功；

手不扶獨坐超過

3分鐘。

2002.01.08

↓

2002.02.08

PT：肌力訓練、坐

姿平衡訓練

居家訓練：配合餵

食及遊戲進行坐姿

及姿勢轉換訓練

直接觀察或

詢問家長

2002.02.08

90%

獨坐1-2

分鐘

1b. 獨立完成躺

←→坐起，1/5

成功；手不扶獨

坐超過5分鐘。

2002.02.09

↓

2002.03.08

PT：肌力訓練、坐

姿平衡訓練




直接觀察或

詢問家長

2002.03.08

100%

1c. 獨立完成躺 2002.03.09 PT：肌力訓練、坐直接觀察或 2002.04.08

73

←→坐起，5/5

成功；手不扶獨

坐超過10分鐘。

↓

2002.04.08

姿平衡訓練




詢問家長 100%

長期目標：2.肚子離地爬4 - 5步。


2a. 肚子貼地爬

3步。

2002.01.08

↓

2002.02.08

PT：誘發手主動動

作，爬行訓練

居家訓練：把玩具

放在稍遠處，協助

孩子用爬行拿到玩

具；或協助孩子爬

向媽媽再抱起

直接觀察或

詢問家長

2002.02.08

100%

可爬4-5

步，偶爾

可見到小

狗趴姿勢

2b. 肚子貼地爬

2-3公尺，偶爾可

見到肚子離地爬

1 - 2步。

2002.02.09

↓

2002.03.08


作，爬行訓練




具；或鼓勵孩子爬

向媽媽再抱起

直接觀察或

詢問家長

2002.03.08

90%

可肚子貼

地爬2-3

公尺，但

雙腳一起

動；給予

輕度協助

可肚子離

地爬2 - 3

步。

2c. 肚子離地爬

4 - 5步。

2002.03.09

↓

2002.04.08


作，爬行訓練




具；或鼓勵孩子爬

向媽媽再抱起

直接觀察或

詢問家長

2002.04.08

100%

可連續爬

2-3公尺

長期目標：3.自行扶著傢俱站起，3/5成功；且扶傢俱站超過10分鐘不倒，可扶

家具側移4 - 5步。


3a.可主動抓著

媽媽站起，且扶

傢俱站超過3分

鐘不倒。

2002.01.08

↓

2002.02.08

PT：姿勢轉換與站

立平衡訓練

居家訓練：鼓勵其

站著遊戲，協助孩

直接觀察或

詢問家長

2002.02.08

100%

74

子扶大人站起再抱

3b. 自行扶著傢

俱站起，1/5成

功；且扶傢俱站

超過5分鐘不

倒，可扶家具側

移1 - 2步。

2002.02.09

↓

2002.03.08


立平衡訓練




直接觀察或

詢問家長

2002.03.08

90%

站起仍需

輕度協

助，但已

可扶家具

側移2-3

步

3c. 自行扶著傢

俱站起，3/5成

功；且扶傢俱站

超過10分鐘不

倒，可扶家具側

移4 - 5步。

2002.03.09

↓

2002.04.08


立平衡訓練




直接觀察或

詢問家長

2002.04.08

100%

長期目標：4.牽兩手走超過3公尺，牽一手走5步。


4a. 牽兩手走1

公尺。

2002.01.08

↓

2002.02.08

PT：行走訓練

居家訓練：短距移

動或遊戲時牽著孩

子走

直接觀察或

詢問家長

2002.02.08

100%

4b. 牽兩手走

1-2公尺，牽一手

走2-3步。

2002.02.09

↓

2002.03.08

PT：行走訓練



子走

直接觀察或

詢問家長

2002.03.08

100%

4c. 牽兩手走超

過3公尺，牽一

手走5步。

2002.03.09

↓

2002.04.08

PT：行走訓練



子走

直接觀察或

詢問家長

2002.04.08

100%

III. 精細動作：（目標發展年齡8-10個月，上肢主動動作達到80%）

長期目標：1.自己吃小餅乾（用拇指與食指指側拿小餅乾），5/5成功。


1a. 在大人協助

控制手指動作下

用拇指與食指指

側拿小餅乾，5/5

成功。

2002.01.08

↓

2002.02.08

PT：誘發手指動作

及手眼協調訓練

居家訓練：配合進

食活動訓練

直接觀察或

詢問家長

2002.02.08

100%

1b.由虎口處給 2002.02.09 PT：誘發手指動作直接觀察或 2002.03.08

75

小餅乾，可用拇

指與食指指側拿

小餅乾，5/5成

功。

↓

2002.03.08



食活動訓練

詢問家長 100%

1c. 自己吃小餅

乾（用拇指與食

指指側拿小餅

乾），5/5成功。

2002.03.09

↓

2002.04.08




食活動訓練

直接觀察或

詢問家長

2002.04.08

100%

長期目標：2.雙手各拿一個玩具可玩5分鐘不放手，4/5成功。


2a. 雙手各拿一

個玩具維持10秒

不掉落。

2002.01.08

↓

2002.02.08

PT：手眼協調訓練

居家訓練：配合遊

戲訓練

直接觀察或

詢問家長

2002.02.08

50%

3/5成功

2b. 雙手各拿一

個玩具可玩1分

鐘不放手，2/5

成功。

2002.02.09

↓

2002.03.08



戲訓練

直接觀察或

詢問家長

2002.03.08

50%

維持30秒

2c. 雙手各拿一

個玩具可玩5分

鐘不放手，4/5

成功。

2002.03.09

↓

2002.04.08



戲訓練

直接觀察或

詢問家長

2002.04.08

50%

維持1分

鐘

長期目標：3.可觀察到單獨食指動作，1天可看到10次以上。


3a. 協助下做出

單獨食指動作。

2002.01.08

↓

2002.02.08


居家訓練：遊戲時

協助孩子做出動作

直接觀察或

詢問家長

2002.02.08

100%

3b. 可觀察到單

獨食指動作，1

天可看到1-2次。

2002.02.09

↓

2002.03.08




直接觀察或

詢問家長

2002.03.08

100%

3c. 可觀察到單

獨食指動作，1

天可看到10次以

上。

2002.03.09

↓

2002.04.08




直接觀察或

詢問家長

2002.04.08

80%

76

IV. 認知及語言：（目標發展年齡8-10個月）

長期目標：1.大人在雙手中交換物品，以1秒交換1次的速度，眼睛能同步跟著

追視，5/5成功。


1a. 大人在雙手

中交換物品，以2

秒交換1次的速

度，眼睛能同步

跟著追視。

2002.01.08

↓

2002.02.08

PT：追視訓練

居家訓練：遊戲或

拿東西給孩子時進

行追視訓練

直接觀察或

詢問家長

2002.02.08

100%

1b. 大人在雙手


秒交換1次的速


跟著追視，3/5

成功。

2002.02.09

↓

2002.03.08

PT：追視訓練



行追視訓練

直接觀察或

詢問家長

2002.03.08

100%

有興趣的

物品追視

得較好

1c. 大人在雙手


秒交換1次的速


跟著追視，5/5

成功。

2002.03.09

↓

2002.04.08

PT：追視訓練



行追視訓練

直接觀察或

詢問家長

2002.04.08

100%

長期目標：2.找到遮蓋在毛巾下的玩具，4/5成功。


2a. 找到遮蓋在

毛巾下的玩具，

玩具部分露出，

3/5成功。

2002.01.08

↓

2002.02.08

PT：認知及視覺追

視訓練

居家訓練：多玩躲

貓貓等遊戲

直接觀察或

詢問家長

2002.02.08

100%

偶爾可找

到遮蓋在

毛巾下的

玩具

2b. 找到遮蓋在


2/5成功。

2002.02.09

↓

2002.03.08


視訓練


貓貓等遊戲

直接觀察或

詢問家長

2002.03.08

100%

2c. 找到遮蓋在


4/5成功。

2002.03.09

↓

2002.04.08


視訓練


貓貓等遊戲

直接觀察或

詢問家長

2002.04.08

100%

77

長期目標：3.可從盒子中拿出玩具，5/5成功；將玩具放入盒子，1/5成功。


3a. 會主動將手

放入盒子中碰到

玩具，2/5成功。

2002.01.08

↓

2002.02.08

PT：認知訓練，加

強容器觀念

居家訓練：將常玩

玩具放入固定的盒

子中，帶著孩子拿

直接觀察或

詢問家長

2002.02.08

100%

4/5成功

3b. 可從盒子中

拿出玩具，1/5

成功。

2002.02.09

↓

2002.03.08


強容器觀念




直接觀察或

詢問家長

2002.03.08

80%

偶爾成功

1次

3c. 可從盒子中

拿出玩具，5/5

成功；將玩具放

入盒子，1/5成

功。

2002.03.09

↓

2002.04.08


強容器觀念




及放

直接觀察或

詢問家長

2002.04.08

50%

可將玩具

放入盒

子，1/5

成功；但

仍不太會

由盒子中

拿出玩具

長期目標：4.模仿1 個常用的語言音，1/5成功；模仿1個常見的手勢，1/5成

功。


4a. 家人常能提

供足夠語言刺

激，並鼓勵其模

仿

2002.01.08

↓

2002.02.08

PT：誘發模仿動作

與語音

居家訓練：誘發模

仿動作與語音，特

別利用餵食時訓練

直接觀察或

詢問家長

2002.02.08

100%

4b. 模仿1 個常

用的語言音，

1/10成功；模仿

1個常見的手

勢，1/10成

功。

2002.02.09

↓

2002.03.08


與語音




直接觀察或

詢問家長

2002.03.08

20%

4c. 模仿1 個常

用的語言音，1/5

成功；模仿1個

2002.03.09

↓

2002.04.08


與語音


直接觀察或

詢問家長

2002.04.08

50%

可模仿

”bye-bye”

手勢，但仍無

78

常見的手勢，1/5

成

功。



法模仿語音

V.生活自理發展：（目標發展年齡10-12個月）

長期目標：1.增加主食及副食品進食量，餵食時會想自己拿起湯匙。


1a.轉介營養師

提供家長，食物

選擇及熱量計算

資訊。

2002.01.08

↓

2002.02.08

PT：協助轉介營養

師

直接觀察或

詢問家長

2002.02.08

100%

增加牛奶濃

度及副食品

量

1b.增加1-2餐副

食品，每餐1/3

碗。協助孩子拿

著湯匙吃麥糊或

稀飯。

2002.02.09

↓

2002.03.08

PT：教導家長協助

餵食技巧

居家訓練：增加點

心時間，協助孩子

拿湯匙進食。

直接觀察或

詢問家長

2002.03.08

100%

偶爾可吃半

碗

1c.增加麵包餅

乾等固體食物

量。可自己拿著

湯匙將食物送到

嘴邊。

2002.03.09

↓

2002.04.08

PT：教導家長協助

餵食技巧

居家訓練：增加點

心時間，協助孩子

拿湯匙進食。

直接觀察或

詢問家長

2002.04.08

80%

79

物理治療計畫：

1.軀幹伸直肌與四肢肌力訓練。

2.誘發上肢主動動作。

3.站姿與坐姿平衡訓練躺坐訓練。

4.鼓勵爬行與雙手扶持行走。

5.精細動作訓練：用手來拿較小物體。

6.雙手協調動作訓練。

7.視覺追視訓練。

8.建立容器概念。

居家訓練計畫：

1.用玩具引誘躺→坐，鼓勵獨自坐著玩。

2.鼓勵爬行與雙手扶持行走。

3.鼓勵用手來拿小餅乾吃。

4.多讓孩童雙手各拿1玩具玩耍。

5.拿東西吸引孩童注視及追視。

6.與孩童玩捉迷藏、找東西的遊戲。

7.將其平常喜歡的玩具收在盒子，裡帶著孩童的手拿出來與放入。

80

範例二：腦性麻痺

4****** 簡** OPD 1

兒童物理治療評估表診斷/併發症： Cerebral Palsy 評估日期： 95-1-13 性別：女生日： 90.6.30 年齡： 4Y6M 電話： 8******* 地址：台北縣*********3樓注意事項：轉介醫師：謝正宜

治療起始時間：物理治療： 95-01-13 職能治療：語言治療：心理治療：

出生史：懷孕週數： 33 出生序： G3P3 出生體重(%)： 1590 g 其它：目前體重(kg / %)： 15 kg 目前身高(cm / %)： 115cm 目前頭圍(cm / %)：48 cm 可能造成發展障礙原因： prematurity 相關檢查結果（x光，腦波，血液檢查等）：X- ray: shallow and subluxation of both hips 疾病史：出生後住在新生兒加護病房一個禮拜後，又保溫一個月才出院治療史（含相關各科及早期療育）：曾在馬偕做物理治療半年，會走後停止。目前是否使用藥物：■ 否，□ 是；藥物名稱及作用：達成發展基石之年齡 (月)：頭部控制 + 翻身比兄姊慢獨坐 1+ y/o 貼地爬 + 離地爬 + 行走(5步) 2y6m/o 說話(5個單字) + 家屬的期待：希望個案能儘早正常走路及跑步。

評估：

1. 環境障礙和整合：家中有三個小孩，哥哥小學六年級，姊姊則是幼稚園大班，家中主要照顧者是媽媽，目前個案的活動範圍很大，家中或到外面都有。家住三樓，能自行扶扶手

上下樓梯。

2. 輔具需求與使用：目前媽媽有給個案的右腳穿矯正鞋。 3. 家中或社區活動(課內外活動)執行與參與：個案還沒上幼稚園，但媽媽有打算要讓她上，所以才前來做評估。目前還是以跟著媽媽或在家中活動為主。 4. 動作控制、協調與學習(包含功能性行走能力、姿勢控制與轉/移位能力等)：可以獨立行走，步態：stance phase : trunk side bending， knee hyperextension in terminal stance phase, foot eversion and left tip toe, right foot entire sole down；swing phase: insufficient toe clearance, insufficient hip flexion走路速度：38公尺/分鐘，跑步速度：85公尺/分鐘，媽媽抱怨個案跌倒的頻率較其他同齡小孩為高，平均一次外出有五次跌倒。動態站姿平衡能力不足，一

推就容易用踏步反應而非足踝策略。還不會單腳站與跳，蹲 (+)，但由蹲站起速度較慢，需手扶，由椅子上站起來或從地上站起來需用手扶，且需試2-3次才成功。無法不扶彎腰

撿物再挺直。喜歡玩球類運動，會接 2公尺外的籃球，丟為過肩丟球，可丟 2公尺遠。

81

5. 警覺性、注意力、認知、行為：有人接近會用眼睛觀察，個性比較內向害羞，可專注在一個活動超過 10分鐘以上，但一般認知皆有跟上發展。

6. 體適能(包含身體組成、心肺耐力、肌力與肌耐力、柔軟度等)：評估 1小時期間皆無出現疲累情形，腹肌、背肌及髖伸肌及外展肌較弱。

7. 身體機能構造(包含關節角度、關節與姿勢變形、感覺知覺、肌張力等)：腳踝有些微的高張力，兩側 hamstring tightness：popliteal angle: R’t 0°-150°, L’t 0°-135°，dorsiflexion: R’t and L’t 0°-5°，腳長：左腳 49公分，右腳 50公分。。其它關節活動度無異常。

8. 其他(如發展評估、職前評估)： CDIIT篩檢量表：認知：47.4M，語言：52.7M，動作：36.5M，社會性：56.0，自理：49.1M。 GMFM66 total score 65

9.相關福利服務（殘障手冊、發展遲緩證明等）：不需已具備需要 V 10. 個案之優勢：個案智能發展正常，母親與個案配合度佳，動機強。主要問題：CP Spastic diplegia GMFCS II

1. 粗大動作發展遲緩：無法獨自從地上或椅子上由坐到站，在爬樓梯時需手扶扶手，無法跑與跳。

2. 異常步態，身體晃動大，墊腳尖，toe clearannce不足。 3. 步速較同年齡的孩童慢，未達功能性行走速度。 4. 站姿平衡能力不足，平衡策略不足。 5. 整體肌力與耐力不足，尤其是核心肌群與下肢肌力不足，導致以上動作功能障礙。 6. 踝關節之角度不足，與輕度高張力易使足部產生永久變形。。

治療目標：（至 95 年 4 月 13 日） 1. 增加自行步速至50 m/min。 2. 減少每次外出跌倒次數至2次。

3. 能從與膝同高的椅子上由坐到站，成功3/5次。

4. 增加腹部、背部及髖部肌肉之肌力。

5. 增加兩腳腳踝的角度至0°-15°，避免足部變形。

6. 出現適應性、預期性與反應性站立平衡反應。

7. 改善步態：降低身體晃動，增加toe clearance。

治療計畫： 1. 針對兩側踝蹠屈肌的牽拉運動。 2. 針對腹肌、軀幹伸直肌、髖屈曲肌、髖伸直肌與髖外展肌的強化運動。

3. 配合使用懸吊系統跑步機訓練，逐步增加速度到50公尺/分鐘，及增加時間到10分鐘。

4. 針對適應性、預期性與反應性坐姿與站立平衡的訓練。

居家訓練計畫： 1. 教導照顧者在家中伸展鈺書兩側腳踝的背屈角度。 2. 針對腹肌、軀幹伸直肌、髖屈曲肌、髖伸直肌與髖外展肌的強化運動。 3. 行走耐力訓練。

治療師簽章：SPT***/PT ***

82

個別訓練計畫方案

主要問題（3/3/2006）：粗大動作發展遲緩，因：

1. 兩側踝背屈被動關節角度不足（0°）。 2. 多數肌群肌力不足，包括腹肌、軀幹伸直肌、髖屈曲肌、髖伸直肌、髖外展肌。 3. 兩側下肢肌耐力不足。 4. 兩側踝蹠屈肌輕度高張（MAS: 1+）。

5. 缺乏適當平衡反應。 6. 步行速度較慢（36 m/min）。

7. 在戶外行走平均跌倒5次以上。

長期目標（至 9/3/2006）： 1. 增加並維持兩側踝背屈被動關節角度0-15° 2. 在仰臥且雙手抱腳向肚子，維持10秒*10次。 3. 在站姿下，手不扶物，能彎下腰撿物再回到站姿10次。 4. 可以連續側走50步。 5. 在雙腳併攏，眼睛睜開，站在枕頭上，能承受來自任意方向的輕推而不失去平衡10次，有

80％不倒。

6. 在懸吊系統的協助下，在跑步機上能以50 m/min速度走10分鐘。 7. 降低跌倒次數，每次從捷運站到醫院平均跌倒小於一次。

1. 增加並維持兩側踝背屈被動關節角度15°

短期目標訓練方法起訖日

期評量方式成果/日期備註

1a. 增加兩側

踝背屈被動關

節角度0-5°

牽拉運動 3/3-5/3 直接測量95/05/03

PROM 0-5°

1b. 增加兩側

踝背屈被動關

節角度0-10°

牽拉運動 5/3-7/3 直接測量95/07/1

PROM 0-5°

1c. 維持兩側

踝背屈被動關

節角度0-15°

牽拉運動 7/3-9/3 直接測量

2. 在仰臥且雙手抱腳向肚子，維持10秒*10次。短期目標訓練方法起訖日期評量方式成果/日期備註

2a. 在仰臥且

雙手抱腳向肚

子，維持10秒

在治療室中練習

與在家中練習 3/3-4/17 直接評量

95/04/17

100％

83

*3次

2b. 在仰臥且

雙手抱腳向肚

子，維持10秒

*6次



2c. 在仰臥且

雙手抱腳向肚

子，維持10秒

*10次



95/06/20

100％

3. 在站姿下，手不扶物，能彎下腰撿物再回到站姿10次。



3a. 在站姿

下，支持兩側下

肢，手不扶物，

能彎下腰撿物

再回到站姿5

次

彎腰撿東西遊戲 3/3-5/3 直接評量95/04/30

7次

3b. 在站姿

下，支持兩側下

肢，手不扶物，

能彎下腰撿物

再回到站姿10

次

彎腰撿東西遊戲 5/3-7/3 直接評量95/06/30

10次

4. 可以連續側走50步



4a. 手可扶欄

杆，可以連續側

走20步直接練習 3/3-5/3 直接評量

95/4/30可

以向左右各

走20步，但

向左走時骨

盆易向後。

4b. 手可扶欄


走40步

直接練習 5/3-7/3 直接評量

4c. 手可扶欄


走50步

直接練習 7/3-9/3 直接評量

84

5. 在雙腳併攏，眼睛睜開，站在枕頭上，能承受來自任意方向的輕推而不失去平衡10次

短期目標訓練方法起訖日期評量方式成果/日期備註

5a. 在雙腳打

開，眼睛睜開站

枕頭上，能承受

來自任意方向

的輕推而不失

去平衡

以遊戲方式直接

練習 3/3-5/3 直接評量

95/04/10

100％

5b. 在雙腳併

攏，眼睛睜開站

在枕頭上，能承

受來自任意方

向的輕推而不

失去平衡3/5



5c. 在雙腳併

攏，眼睛睜開站

在枕頭上，能承

受來自任意方

向的輕推而不

失去平衡10次



6. 在懸吊系統的協助下，在跑步機上能以50 m/min速度走10分鐘。短期目標訓練方法起訖日期評量方式成果/日期備註

6a. 在懸吊系

統的協助下，在

跑步機上能以

40 m/min速度

走5分鐘

跑步機訓練 3/3-5/3 直接測量

95/05/03

以40m/min

速度走3分

及跟不上速

度。

耐力不

足，宜

降低目

標

6b. 在懸吊系


跑步機上能以

40 m/min速度

走10分鐘


95/06/10

穿AFO走在

平地速度

>50m/min，

走10分鐘

以上。

6c. 在懸吊系


跑步機上能以

45 m/min速度

走5分鐘


85

6d. 在懸吊系


跑步機上能以

50 m/min速度

走3分鐘

跑步機訓練 9/3-11/3

6e. 在懸吊系


跑步機上能以

50 m/min速度

走10分鐘

跑步機訓練 11/3-12/3

7. 降低跌倒次數，每次從捷運站到醫院平均跌倒小於一次。短期目標訓練方法起訖日期評量方式成果/日期備註

7a. 每次從捷

運站到醫院平

均跌倒小於3

次

每週詢問母親從

捷運站到治療室

跌倒次數與原

因，評量跌倒原

因並加予訓練

3/3-5/3 直接詢問

95/05/05

平均跌倒3

次，多是腳

踢到人行

道，主因

toe

clearance

不足

7b.每次從捷運

站到醫院平均

跌倒小於2次



跌倒次數與原


因並加予訓練

5/3-7/3 直接詢問

95/06穿了

AFO後跌倒

情形明顯改

善，很少跌

倒。

目標達

到。

7c.每次從捷運

站到醫院平均

跌倒小於1次



跌倒次數與原


因並加予訓練

7/3-9/3 直接詢問

86

範例三：新生兒國立台灣大學醫學院附設醫院

復健部物理治療報告單（新生兒評估）病歷號 12354567 姓名何 XX 床號 5FI 01-1 第 1 頁

Physical Therapy Note for Newborn Baby Date 95-12-21

v Initial Note Acceptance Note Summary Note Discharge Note I. Basic Data Sex male Date of Birth 95-11-28 Gestational Age 30+6 weeks Birth Body Weight 1204gm (25﹪) Body Length 40㎝ Head Girth 28㎝ Apgar Score at 1 min 7 at 5 min 9 Birth History:

This 23 d/o premature baby was born by a G3P2AA1 mother via C/S. Steroid was given before delivery. After delivery, weak spontaneous crying with general cyanosis was noted. Skin color became pink and activity improved after O2 therapy and tactile stimulation. Under the impression of prematurity with VLBW, he was admitted to the NICU for further management. Impression 1) Prematurity 2) Respiratory distress, R/O transitional tachypnea of the newborn 3) R/O RDS

Date of Admission 95-11-28 Medical Finding (CT, Brain echo, EEG, EKG……ect.): 1st brain ECHO (12/02/2005): Left colpocephaly, cavum septum pellucidum, cavum vergae 2nd brain ECHO (12/05/2005): Ditto 3rd brain ECHO (12/19/2005): Ditto, except R/O left ventriculomegaly Other Medical Problems: Nil Maternal History:

Maternal pre-eclampsia and GDM were noted at the GA of about 28 wks. Antihypertensive agents were given for BP control. Blood sugar was stable under diet control. Due to uncontrolled BP, elective CS was performed on 11/28/2006. Other Medical Problems: Nil. Mother’s name 李 XX education 大學 occupation 教師 Father’s name 何 XX education 大學 occupation 教師

Date of PT Start 95-12-21

II. Brief History At the NICU, respiratory distress was noted and NCPAP was immediately given. The microbubble test was very weak, but CXR did not demonstrate RDS patterns. Apnea with desaturation was noted. The NCPAP mode was shifted to the NIPPV mode on 11/29/2006. Apnea improved on 11/30/2006, and the NIPPV mode was shifted back to the NCPAP mode and to NC on 12/01/2006. His respiratory condition had been stable since 12/04/2006.Phototherapy was given for hyperbilirubinemia and DC on 12/11/2006. He had started GI priming since 12/02/2006 with partial parenteral nutrition support. His feeding condition was smooth and TPN was tapered off on 12/15/2006. PT was consulted for further assessment and management. III. Physical Examination 1. Vital Sign (HR, RR, SaO2): resting HR/RR/SaO2 : 128-145bpm/48-54次/min/100﹪ handling HR/RR/SaO2 : 136-157bpm/45-65次/min/95-98﹪ 2. Range of Motion: WNL

87

國立台灣大學醫學院附設醫院復健部物理治療報告單（新生兒評估）

病歷號 3991455 姓名何 XX 床號 7C11-1 第 2 頁 3. Sensation: withdraw to pain stimulation (+), hypersensitivity (+) 4. Breathing Condition: a. Breathing Sound: clear BS b. Breathing Pattern: Synchronised and symmetric expansion 5. Neonatal Neurobehavioral Examination (NNE)(See the special sheet): Conceptional Age 33wks Total Score 54 a. Tone and Motor Pattern (Section score: 17 ) b. Primitive Reflex (Section score: 16 ) c. Behavior Responses (Section score: 21 ) 6. MMT: weak grasping strength, poor antigravity movement of bilateral U/E and L/E (less midline activity of U/E and poor weight bearing ability and kicking movement of L/E) 7. Muscle Tone: increased neck extensor tone (opisthotonos) 8. Oral Function: NG feeding, poor sucking power and endurance (only persistent 3~5 times/beat), easily desaturation during oral feeding due to poor sucking-swallowing-breathing coordination IV. Major Problem 1. Irritability during our handling, hypersensitivity to environment stimulation 2. Insufficient head righting ability (pull to sit, prone suspension) 3. Insufficient sucking power/endurance and sucking-swallowing-breathing coordination 4. Insufficient visual/auditory reactions and oculomotor coordination 5. Increased muscle tone of neck and four limbs muscle 6. Insufficient weight bearing ability of lower extremities V. PT Goal 1. Calm down by himself 2. Improve head righting ability 3. Improve oral function and coordination 3. Improve visual/auditory orientation ability and oculomotor coordination 5. Normalize muscle tone of neck and four limbs muscle 6. Improve weight bearing ability of lower extremities VI. PT Program 1. Therapeutic positioning and joints approximation to normalize muscle tone and activate selective motor pattern 2. Passively rolling to improve head righting control 3. Facilitate U/E midline activity 4. L/E weight bearing training 5. Oral-motor skills training, including oral massage, sucking power and endurance training, and oral coordination training 6. Visual/auditory orientation training and oculomotor coordination training 7. Calming technique and desensitizing exercise if necessary PT would emphasize those treatment programs and counsel those programs to parents. Further rehabilitation treatment from our OPD after discharge was suggested. SPT Sign: 林 XX / PT Sign: 鄭 XX

88

範例四：病房兒童物理治療



病歷號 4066143 姓名朱 XX 床號 7C 07-2 第 1 頁

Physical Therapy Note for Bedside Pediatric Patients v Initial Note Acceptance Note Summary Note Discharge Note

I. Basic Data Sex: Female Age: 11M/O (Birth Date: 90-4-27) Date: 91-3-11 Date of Admission: 91-2-6 Date of Onset: 90-4-27 Impression: 1. MAS 2. Holoprosencephaly 3. Cerebral palsy with SQ Medical Findings:(CT,EEG.....etc) 1. MRI (at brain): agenesis of corpus callosum. 2. Chromosome study: 46XX3. 3. EEG (2/7,2/28): moderate diffuse cerebral dysfunction, fast activity over bilatory frontal lobes. Other Medical Problems: 1. UGI bleeding. 2. ARF (hyponatremia, hypokalemia). 3. bronchopneumonia. 4. laryngomalacia 5. moderate GER Reasons for Consulting PT: for development delay and poor sucking Date of PT Starting: 91-3-11 Brief History

This 11m/o female (G2P1AA1, NSD, GA 39 wks, BBW 2300 gm, DOIC(+), MAS) baby was a case of MAS who admitted to 恩主公 H since birth. She had admitted to 恩主公 H for many times since birth due to bronchopneumonia. Laryngomalacia was impressed, and she was brought to our ENT ward for bronchoscope examination during 90-10-8 to 12-20. The result was prominent arytenoids and shortened aryepiglottic fold. Neonatal seizure was noted on 90-6-27 with lip cyanosis and eye blinking but EEG didn’t show spike. Infantile spasm was noted on 91-10-19 with tonic spasm. She admitted to 恩立公 H again due to dyspnea and poor activity for one day on 90-12-25. She was intubated due to impending respiratory failure. ARF was noted on 91-1-30, UGI bleeding was found on 91-2-3. Due to her repeated extubation failure. She was transferred from 恩主公 H to NTUH for further help. II. Physical Examination Consciousness/Mentality: 晚上很躁動,睡不好,白天晚起. Cooperation/Motivation of the Child/Parents: G / G; G/G Vision/Hearing: weak response to auditory and visual stimulation from right side; poor oculomotor coordination Communication/Feeding: respond to voice / NG feeding mostly, poor sucking power and endurance (only persistent 3~5 times per beat), chorea-like motion to tongue Cardiopulmonary Function: breathing sound: diffused, coarse (+), rhonchi (+) breathing pattern: see-saw type, intercostals muscles retraction (+), insufficient chest mobility Sensation: hypersensitivity (-); withdraw reaction to pain stimulation (+) Muscle Tone: fluctuated muscle tone, general hypotone at rest, mild increased muscle tone of four limbs during action ROM: WNL MMT: weak grasping strength, poor antigravity movement of bilateral L/E

89



病歷號 4066143 姓名朱 XX 床號 7C 07-2 第 2 頁

Developmental Status: (evaluation tool: EIDP) GM: DA 1-2 m: 1. no head lag (-). 2. head raises and maintains at 30°(+)

3. kicking with alternating feet in supine (+) FM: DA 1-2 m: 1. reaching (-) 2. grasping reflex (+)

3. finger playing at midline (-) 4. looks at hand (-) 5.chorea-like movement of hands

Functional Status: all dependent III. Major Problems: 1. Abnormal muscle tone of four limbs result to less voluntary movement. 2. Insufficient muscle strength of trunk and extremities. 3. Poor sucking ability and oral coordination 4. Insufficient auditory and visual orientation and oculomotor coordination 5. Poor lung hygiene and breathing pattern. 6. Severe GM and FM delay IV. Physical Therapy Goals:

STG: 1. Improve sucking endurance more than 10 times per beat 2. Improve auditory and visual orientation 3. Improve lung hygiene LTG: 1. Induce voluntary movement. 2. Prevent contracture of joints or other complications due to immobilization 3. Counseling to parents about handling and points for attention. 4. Improve GM and FM development. V. PT Programs: 1. PROM and gentle stretching exercise 2. Well positioning and facilitation for activation voluntary movement and normalize muscle tone 3. Rolling exercise with pelvic support to facilitate head righting and trunk control ability.. 4. Oral massage and sucking power training. 5. Hearing and visual orientation training. 6. Chest care including percussion and posture drainage. VI. Home Programs: 1. As all PT programs. 2. Suggest further rehabilitate courses from OPD after DC from NTUH. SPT Sign: 林 xx / PT Sign: 陳 xx

90

病房物理治療每日記錄（兒童疾患）

Bedside Physical Therapy Daily Note (Pediatric Patient) Date

Physical Examination

1. Consciousness (state)

2. HR/RR/ SaO2 (resting/handling)

3. Sucking power/endurance

Suck-swallow-breath coordination

4. Visual/auditory reactions

5. Movement pattern

6. Muscle tone

7. Self-regulatory behavior

8. NNE total score

Tone and motor pattern

Primitive reflexes

Behavioral responses

9. Alberta Infant Motor Scale score

10. Developmental status Intervention programs 1. Therapeutic positioning

2. U/E midline activity facilitation

3. L/E weight bearing training

4. Head righting training

5. Oral-motor skills training

6. Oculomotor coordination training

7. Visual/auditory orientation training

8. Vestibular system stimulation

9. Desensitizing exercise

10. Passive chest mobility exercise

11. Percussion / postural drainage ˇ

12. Social interaction facilitation

13. PROM exercise

14.Treatment programs counseling ˇ

Sign

91

骨科疾患相關病歷格式與範本

（1）肌肉骨骼疾患評估

93

（2）Physical Therapy for Shoulder joint

Physical Therapy for Shoulder Joint I. BASIC DATA: Age:_____ Gender: ○M ○F DATE:____/____/____Date of PT starting: ____/____/____ Impression: Involved shoulder: □right □left Dominant shoulder:□ right□ leftWork status:□Not working□Working Brief history: (Onset, causes, duration, pain status, affecting factors, and previous history) night pain:__; Visual analog scale: Does pain increase in the previous one month □yes□no Frequency: □ pain all the time □ per day □ per week

II. PHYSICAL EXAMINATION: 1. Observation: Shoulder Posterior view □Both sides are horizontal □Elevated/depressed

Shoulder Lateral view □Plumb bisects acromion □Tilt □Forward (round shoulder)

Scapula Posterior view □Medial borders are

parallel, about 2” from the spine

□Adducted / Abducted

□Downward / Upward rot

□Elevated / Depressed

Scapula Lateral view □Scapula held flat against

the thorax, 30° anterior to

frontal plane

□Winged

□Tipped Anteriorly

Humerus posterior view □Olecranon processes face

posteriorly

□Internally/Externally rotated

Humerus lateral view □Distal humerus vertically

in line with the proximal humerus

□Distal humerus anterior/

posterior to the proximal

2. Palpation: □ supraspinatus insertion □biceps long head/short head □subscapularis □ infraspinatus

□ ____________________ 3. Selective tissue tension test Active:

Pain1;Willingness1 Passive: Pain1,2; Endfeel3

Resisted: Pain1; Strength4

Flexion Abduction Internal rotation External rotation

1 +: positive; -:negative 2. Range: initial, mid, end 3 Hard, firm, soft, empty 4 Strong, weak

94

4. Range of motion Left arm Movement Right arm Flexion Abduction Internal rotation arm by side/90 degrees abd External rotation arm by side/90 degrees abd Anterior/posterior tightness5 5. Joint play: distraction Anterior-posterior6 Superior-inferior6 Glenohumeral joint: Scapulothoracic joint: Acromioclavicular Joint: 6. Muscle dysfunction test7:muscle tightness______________________ muscle weakness___________________________________________ 7. Functional activity □HAND-IN-NECK; □HAND-TO-SCAPULA; □HAND-TO-OPPOSITE SCAPULA; □MODIFIED KIBLER’S LATERAL SCAPULAR SLIDE TEST 8. Special test □ Impingement test □ Neer impingement test, □ Hawkins impingement test □ painful arc of movement (60°–120°) □Empty can test □Speed test □ ______________ □ ______________ □ ______________ III. ASSESSMENT: (Problems and reasons should be added.)

□ tenderness at_______________________________________________ □ muscle spasm end feel at R’t /L’t shoulder ______________________ □ R’t /L’t shoulder joint ROM limitation at_______________________ □ Joint play hypomobility at_____________________________________ □ Functional limitation of _____________________________________

IV. PT PROGRAMS: □ Hot packing □ IFC □ USD/Laser at___________________ □ Joint mobilization □ stretching exercise for___________________

HOME PROGRAMS: □Pendulum ex □scapular setting ex □ROM ex__________________

□ Stretching exercise for____________________________________ □ Strengthening exercise for____________________________________ Sign of PT_______________________

5 Additional information 6 Hyper or hypo mobility 7 Selected muscles as appropriate; +:positive (strong or tight); -:negative (weak or no tight); ne: not examination; na: not available

95

（3）Physical Therapy Assessment for Low Back Pain Initial Evaluation Summary Discharge note

Basic Information Gender:____ Date of birth:________ Age:_____ Occupation:_________ Phone #:__________ Impression:____________________________ Date of PT starting:_________________ Referral Doctor:___________

Brief History Chief Complaints: Medication: Past History: Image Study: Physical Examination: Pain status: Sites and boundaries of pain

Nature of pain: deep aching sharp pain shooting pain Radiation of pain/numbness: to the buttocks to the iliac crest to the anterior abdominal wall down to the hip down to the knee down to the ankle Associated symptoms: morning pain or stiffness night pain burning tingling

numbness itching parasthesia anesthesia Aggravating factors: ____________________Easing factors: ____________________

Observation and Inspection Lumbar lordosis: within normal limit hyperlordosis flat back Lateral shift: within normal limit shoulder shifts to right shoulder shifts to left Others: ___________________________________

Palpation Height of bilateral iliac crest: symmetry right side higher left side higher Height of bilateral ASIS: symmetry right side higher left side higher ________ Height of bilateral PSIS: symmetry right side higher left side higher ________ Tenderness at supraspinous ligaments: none L1 L2 L3 L4 L5 Tenderness at interspinous ligament: none L1 L2 L3 L4 L5 Others: (e.g. paraspinal muscle spasm)_________________

Standing flexion test pain status : none increased decreased during motion end range pain fullness of lumbar paraspinal muscles: symmetry right side higher left side higher pathway: smooth deviation to right deviation to left PSIS excursion: symmetry right PSIS gliding further left PSIS gliding further Sitting flexion test PSIS excursion: symmetry right PSIS gliding further left PSIS gliding further

McKenzie test: lateral shift: : ↑ pain ↓ pain unable to be tested flexion/repeated flexion in standing: ↑pain ↓ pain unable to be tested

extension/repeated extension in standing: ↑ pain ↓ pain unable to be tested

96

flexion/repeated flexion in supine: ↑ pain ↓ pain unable to be tested extension/repeated extension in prone: ↑ pain ↓ pain unable to be tested Movement test: Sidebending to R’t/L’t- Rotation to R’t/L’t-

Spring test: pain: none L1 L2 L3 L4 L5 hard endfeel: none L1 L2 L3 L4 L5 hypomobility/hypermobility(↓/↑): none L1 L2 L3 L4 L5 Flexibility: hamstring_______ gastrocnemius________ quadratus lumborum________ piriformis________iliotibial band_________ hip ROM Thomas test others__________

Muscle strength/endurance Transverse abdominus______ multifidus_______ others________ Neurological examination: hip flexion (L2) knee extension (L3) ankle dorsiflexion, heel

walking (L4) big toe extensor (L5) ankle eversion/hip extension (S1) knee flexion, toe walking (S1-2) patellar reflex (L4) Achilles reflex (S1)

Special test: SLR Slump test Femoral nerve traction test Segmental instability test Patrick test Gillet’s test Long sitting test Functional activities_________________________________________________________ PT Assessment asymmetric posture pain insufficient range of motion at insufficient joint play at muscle strength imbalance of muscle weakness of neurological involvement at decreased functional level PT Programs_______ times per week Physical agents: hot packing for 20’ interferential therapy for 15’ SW for 20’ USD laser TENS lumbar traction with ____________ kg for 20’;hold/relax=___sec/___sec Manual therapy: soft tissue mobilization at _________________________________ joint mobilization at ______________________________________________level (s) others__________________________________________________________ Therapeutic exercises: Home Programs Sign of Physical Therapist:_________________________________

97

（4）Physical Therapy Assessment for Cervical Syndrome

Physical Therapy Assessment for Cervical Syndrome Initial Evaluation Summary Discharge note

Basic Information Gender:_____ Date of birth:_________ Age:_____ Occupation:___________ Phone #:__________ Impression:____________________________ Date of PT starting:_________________ Referral Doctor:___________ Date of referral:___________ Brief History Chief Complaints: Present since:__________ as a result of: Medication: nil/ NSAIDS/ Steroids/ Anticoag/ other Past History: Image Study:

Physical Examination:

1. Pain status:Sites and boundaries of pain (body chart) Nature of pain: deep aching sharp pain shooting pain Radiation of pain: to the lower 1/3 to the middle 1/3 to the upper 1/3 of the scapula

down to the shoulder down to the elbow down to the wrist/fingers Associated symptoms: morning pain or stiffness night pain burning tingling

numbness itching parasthesia anesthesia dizziness/tinnitus/nausea Aggravating factors: ___________________Easing factors:__________________________ 2. Observation and Inspection Posture: sitting: good/ fair/poor Cervical lordosis: within normal limit hyperlordosis flat neck Head position : within normal limit forward head retracted head Torticollis: within normal limit sidebending to right sidebending to left Shoulder posture: Height of bilateral acromia: symmetry right/left side higher 3. Palpation Tenderness at suboccipital muscles: none right painful left painful Skin mobility test: Others: (e.g. paraspinal muscle spasm)__________________________________ 4. Gross mobility tests (pain status*/ROM/end-feel)( * (-): none; (↑): increased; (↓): decreased) Cervical protrusion/flexion_______________________________________________________

Cervical retraction/extension_____________________________________________________ Cervical sidebending to right/left__________________________________________________ Cervical rotation to right/left_____________________________________________________ 5. Repeated test in____________: centralise/peripheralise/worse/no effect

98

5. Segmental mobility tests (pain:+/hypomobility↓) Right /Left side-gliding test in flexion/extension none C2 C3 C4 C5 C6 C7 P/A glide/A/P glide none C2 C3 C4 C5 C6 C7 6. Flexibility: Scalenus anterior________ scalenus middle_________ scalenus posterior________ neck extensors________ trapezius________ SCM_________ levator scapula________others______________________________ 7. Neurological examination (*check if weakness)

neck flexion(C1,C2) neck side flexion(C3) shoulder elevation(C4) shoulder abduction (C5) elbow flexion(C6) elbow extension(C7) wrist flexion(C7) thumb extension(C8)

finger abduction(T1) ULTT1 ULTT2 ULTT3 ULTT4 DTR for ______

8. Muscle strength/endurance___________________________________________________ 9. Functional activities: ______________________________________________________ 10. Special tests: vertebral artery insufficiency test compression distraction PT Assessment

asymmetric posture________________________________________________________ pain insufficient range of motion at insufficient joint play at muscle strength imbalance of muscle weakness of neurological involvement at decreased functional level

PT Programs_______ times per week Physical agents: hot packing for 20’ interferential therapy for 15’ SW for 20’ USD laser TENS cervical traction with ____________ kg for 20’;hold/relax=____sec/____sec Manual therapy: soft tissue mobilization at joint mobilization at the others__________________________________________________________ Therapeutic exercises: Goals: Home Programs: Sign of Physical Therapist:

99

復健部物理治療評估報告 Physical Therapy Evaluation Note for Orthopedic Patients I. Basic Data 年月日Impression: Age: y/o; Gender: □ male; □ female; Date of admission: Date of referral: Past medical history: Precautions : Operation method (Operation date: / / ; Operator: ) Reasons for referral: □ ambulation training; □ ROM exercises; □ strengthening; □ others: Patient or family expectations : Major caregiver: ; Home environment: □ 1F; □ >2F, no elevator; □ elevator II. Physical Examination 1. C/C: 2. Motivation / Cooperation : □ good □ fair □ poor; 3. Mentality: □ able to follow order; □ impaired 4. Pain: □ severe; □ moderate; □ mild (area: ); □ none 5. Swelling: □ severe; □ moderate; □ mild (area: ); □ none 6. Sensation: 7. ROM: 8. Strength of involved extremity : □ weak and non-functional; □ functional strength 9. Strength of uninvolved extremity : □ normal; □ generally weak; □others: 10. Functional status : □ bed ridden; □sit on bed; □sit at bed side; □standing; □ ambulation; □ W/C-bound; □ up/down stairs; □ others

III. Assessment □ Wound pain and swelling □ Poor circulation □ Decreased function status : □ Request for assistive devices use or improper use □ Decreased ROM : □Insufficient muscle strength: □ General deconditioning □ Less knowledge in postoperative care □ Others: IV. PT Goals at Discharge from Ward □ Decrease swelling and pain. □ Motor function □ ambulation with device. Device : □ independent; □ supervised; □ assisted □ W/C activity: □ independent; □ supervised; □ assisted □ bed mobility and transfer: □ independent; □ supervised; □ assisted

□ Increase ROM of ○R / ○L / ○B joint to □ Enhance strength of □ Patient and caregiver understand the precautions / contraindications according to the surgery. V. PT Programs : □ Pumping and isometric exercises to LE / UE. □ Functional training □ ROM exercises □ Strengthening exercises □ Patient and/or caregiver education □ Others:

SPT / PT

民國

年

月

日病歷委員會修正通過



100

復健部物理治療每日記錄 Physical Therapy Daily Note for Orthopedic Patients Imp:

Date Physical Examination

CMS Swelling / Pain Local heat/ Hemovac

ROM: joint

Strength of UE / LE

Functional Status Rolling to R/L side Supine ←→ Sit Sit ←→ Stand W/C Activity Ambulation Assistive Device Weight Bearing Gait Pattern Up/Down Stairs

Treatment Programs PROM to UE / LE AAROM to UE / LE AROM to UE / LE Ankle Pumping Quadriceps / Gluteus Setting Knee Muscles Strengthening Hip Muscles Strengthening

Isometric E’x to

Stretching to

Strengthening to

Bed Mobility Training Sitting & Balance Training Standing & Balance Training Gait Training Transfer training Up/Down Stairs Training Check Out Assistive Devices

SPT/PT Sign

Min: minimal; Mod: moderate; Max: maximum; A: assistance; C: contact guard; S: supervised; I: independent; NA: not available; NT: not test

民國

年

月

日病歷委員會通過



101

範例一：肩部疾患

Physical Therapy for Shoulder Joint V. BASIC DATA: Age:50 Gender: ○M ○F DATE: 95/4/26 Date of PT starting: 95/4/26 Impression:frozen shoulder,shoulder sprain Involved shoulder: ■right □left Dominant shoulder: ■ right□leftWork status: ■Not working□Working Brief history: (Onset, causes, duration, pain status, affecting factors, and previous history) The 50Y/o female patient suffered from R’t shoulder pain since 1 month ago. She had difficult in putting her hand to back. She visited our OPD for help and took some medication but in vain. So PT was consulted. PT started on 95.4.26. night pain: - ; Visual analog scale:4-5 Does pain increase in the previous one month ■yes□no Frequency: □ pain all the time □ per day □ per week

VI. PHYSICAL EXAMINATION: 3. Observation: Shoulder Posterior view ■Both sides are horizontal □Elevated/depressed

Shoulder Lateral view □Plumb bisects acromion □Tilt ■Forward (round shoulder)

Scapula Posterior view □Medial borders are

parallel, about 2” from the spine

■Adducted / Abducted

□Downward / Upward rot

□Elevated / Depressed

Scapula Lateral view □Scapula held flat against

the thorax, 30° anterior to

frontal plane

□Winged

■Tipped Anteriorly

Humerus posterior view □Olecranon processes face

posteriorly

■Internally/Externally rotated

Humerus lateral view ■Distal humerus vertically

in line with the proximal humerus

□Distal humerus anterior/

posterior to the proximal

4. Palpation: ■supraspinatus insertion □biceps long head/short head □subscapularis □ infraspinatus

□ ____________________ 3. Selective tissue tension test Active:

Pain8;Willingness1 Passive: Pain1,9; Endfeel10

Resisted: Pain1; Strength11

Flexion ＋ good － firm ＋ strong Abduction ＋ good － firm ＋ strong Internal rotation － good ＋ firm － strong External rotation ＋ good － firm ＋ weak 4. Range of motion

8 +: positive; -:negative 2. Range: initial, mid, end 3 Hard, firm, soft, empty 4 Strong, weak

102

Left arm Movement Right arm Flexion 0-145。 Abduction 0-120。 Internal rotation arm by side/90 degrees abd 0-60。 External rotation arm by side/90 degrees abd 0-70。 Anterior/posterior tightness12 5. Joint play: distraction Anterior-posterior13 Superior-inferior6 Glenohumeral joint: hyhomobility hyhomobility hyhomobility Scapulothoracic joint: normal normal normal Acromioclavicular Joint: normal normal normal 6. Muscle dysfunction test14:muscle tightness______________________ muscle weakness _supraspinatus muscle_ 7. Functional activity (0)HAND-IN-NECK; (1)HAND-TO-SCAPULA; (2)HAND-TO-OPPOSITE SCAPULA; (2)MODIFIED KIBLER’S LATERAL SCAPULAR SLIDE TEST 8. Special test □ Impingement test □ Neer impingement test, □ Hawkins impingement test □ painful arc of movement (60°–120°) ▓Empty can test □Speed test □ ______________ □ ______________ □ ______________ VII. ASSESSMENT: (Problems and reasons should be added.)

▓tenderness at__supraspinatus tendon____ ____________ □ muscle spasm end feel at R’t /L’t shoulder _____________________ ▓R’t /L’t shoulder joint ROM limitation at_______________________ ▓Joint play hypomobility at__R’t shoulder joint__ __________ ▓Functional limitation of _____________________________________

VIII. PT PROGRAMS: ▓Hot packing □ IFC ▓USD/Laser at___________________ ▓Joint mobilization ▓stretching exercise for___________________

HOME PROGRAMS: □Pendulum ex □scapular setting ex ▓ROM ex__________________

▓Stretching exercise for____________________________________ ▓Strengthening exercise for____________________________________ Sign of PT_______________________

12 Additional information 13 Hyper or hypo mobility 14 Selected muscles as appropriate; +:positive (strong or tight); -:negative (weak or no tight); ne: not examination; na: not available

103

Physical Therapy Evaluation Note Date: I. Basic Data Sex: Age: Date of starting PT: Impression: Past medical history: Smoking history: Preoperative physical status: Date of operation: Date of leaving ICU: Operation finding: Operation type and procedure: Precaution and contraindication: PT was consulted for □cardiopulmonary function training, □chest care, □breathing retraining, □exercise training. II. Physical Examination Consciousness: Cooperation: Resting vital sign: PR: /min; BP: mmHg; RR: /min; SaO2: %; CVP: Inspection: Ventilator: Auscultation: Cough: Sputum: ROM: Activity level: □Bed ridden □Sitting: □Standing: □Ambulation: □Stairs: Exercise endurance: Sign and symptoms during exercise: III. Main Problems IV. PT Goals V. PT Programs 物理治療師:


復健部物理治療報告單(胸腔疾患評估)

民國86

年6

月10

日病歷委員會審核通過

104

Bed Side Physical Therapy Daily Note (Cardiopulmonary conditions) Examination Date

Consciousness /Cooperation PR(bpm) BP(mmHg) RR(min-1) CVP(mmHg)/ SaO2 Ventilator (Mode, Rate, FiO2, PS, PEEP) Breathing sound Cough Sputum ROM Others

Treatment 1. Orientation 2. Regional breathing

Diaph. breathing 3. Postural drainage /Position

Location Percussion/ Vibration

4. Incentive spirometer 5. Arm & leg ex. In bed 6. Chest mobility ex. 7. Reconditioning 8. Postural correction

Activity level 1. Bed ridden 2. Sit on bed (min) 3. Sit on chair (min) 4. Assume to standing 5. Ex. at bedside (standing) 6. Ambulation

Speed (or METs) Time (min) HR (before/after) BP (before/after) RR (before/after)

7. Stairs(S/F) HR (before/after) BP (before/after) RR (before/after)

8. Sign and Symptoms during ex.

Sign

Remarks Post operative complication: □atelectasis, □pneumonia, □pleural effusion, □pneumothorax, □pulmonary edema,

□ARDS; □Others: Note: 1. Sputum amount N: no; S: small; M: moderate; L: large 2. Sputum Color: W: white; Y: yellow; G: green; H: hemoptysis

3. ROM: F: full; L: limited; R’t: right; L’t: left; Bil: bilateral 4. Position of postural drainage: C: classical; M: modified; S: sidelying


復健部病房物理治療每日紀錄（呼吸循環系統）


(MR09-16-43)

民國93

年12

月1

日病歷委員會通過

105

復健部物理治療心肺疾病運動訓練病患狀況記錄表性別：年齡：診斷：運動測試日期： Phase：運動訓練預期之心跳數：無氧閾值：（Watt, mph%）， METs 危險分級： L I H

日期狀況

WL HR BP WL HR BP WL HR BP

訓練期 RPE

備註

治療師

日期

狀況

WL HR BP WL HR BP WL HR BP

訓練期 RPE

備註

治療師


病歷專用紙


民國

年

月


106

復健部冠狀動脈手術臨床路徑物理治療計畫表物理治療師

日期治療項目其他(變異原因) 治療項目

HR: BP:

HR: BP:

HR: BP:

HR: BP:

HR: BP:

HR: BP:

HR: BP:

0-1 手術前物理治療評估、簡介與指導 1-1胸腔物理治療，包括姿位引流、扣擊與抽痰1-2橫膈腹式呼吸及咳嗽訓練 1-3協助式上下肢關節運動，5下/次，建議每日 3次。 2-1主動式上下肢關節運動，5下/次，建議每日 3次。 2-2 Triflow 或 Coach訓練，建議每小時 6下 (睡眠時除外)。 2-3 恢復運動：病人可坐在床邊 min。 3-1恢復運動：坐在椅子上 min。 3-2恢復運動：扶持下站立 min。 3-3恢復運動：原地踏步 min。 4-1以慢速（1.5-2.0 METs）行走 3分鐘建議每日 3次。 4-2 胸腔活動度訓練，建議每日 3次。 4-3矯正不良姿勢。 5-1以慢速（2.0-3.0 METs）行走 3分鐘，建議每日 3次。 5-2 指導出院後居家心臟復健物理治療計劃，包括心跳與血壓的測量。 6-1增加行走速度（2.5-3.5 METs）行走 3-5分鐘建議每日 3次。 6-2 上下 6-12階樓梯。 6-3 確認出院後居家心臟復健物理治療計劃之執行

加護病房：年月日到年月日手術後合併症： □建議出院後一個月後可至復健科門診掛號接受運動測試及心臟復健訓練變異原因 A: 病情不穩定，非物理治療適應症；B: 身體不適；C:病患拒絕；D: 兩次探訪病患不在病房；E: 其他


病歷專用紙


民國

年

月


107

復健部心房/心室中膈缺損手術（年齡大於 10歲）臨床路徑物理治療計畫表

物理治療師

日期治療項目其他(變異原因) 治療項目

HR: BP:

HR: BP:

HR: BP:

HR: BP:

HR: BP:

HR: BP:

HR: BP:

0-2 手術前物理治療評估、簡介與指導 1-1胸腔物理治療，包括姿位引流、扣擊與抽痰1-2橫膈腹式呼吸及咳嗽訓練 1-3協助式上下肢關節運動，5下/次，建議每日 3次。 2-1主動式上下肢關節運動，5下/次，建議每日 3次。 2-2 Triflow 或 Coach訓練，建議每小時 6下 (睡眠時除外)。 2-3 恢復運動：病人可坐在床邊 min。 3-1恢復運動：坐在椅子上 min。 3-2恢復運動：扶持下站立 min。 3-3恢復運動：原地踏步 min。 3-4以慢速（1.5-2.0 METs）行走 3分鐘建議每日 3次。 4-1 胸腔活動度訓練，建議每日 3次。 4-2矯正不良姿勢。 4-3 以慢速（2.0-3.0 METs）在病房外行走 3分鐘（約 50公尺），建議每日 3次。

5-1增加行走速度（2.5-3.5 METs）行走 3-5分鐘建議每日 3次。 5-2 上下 6-12階樓梯，建議每日 3次。 5-3 指導並確認出院後居家心臟復健物理治療計劃，包括心跳與血壓的測量

加護病房：年月日到年月日手術後合併症：變異原因 A: 病情不穩定，非物理治療適應症；B: 身體不適；C:病患拒絕；D: 兩次探訪病患不在病房；E: 其他


病歷專用紙


民國

年

月


108

範例一：CABGⅠ Initial PT Evaluation Note of a Patient Receiving CABG（範本） Initial PT Evaluation Note

87-5-20

This 79-year-old male patient suffered from chest tightness and exertional dyspnea since 1988. He received

regular follow-up and the cardiac catheterization revealed 3-vessel disease last December. The frequency of chest

discomforts increased recently. He was then admitted and received CABG (Ao SVG PDA, Ao SVG OM1,

Ao SVG LAD) on 87-5-19. PT started on 87-5-20 for post operative chest care and cardiac rehabilitation phase I

program.

Risk profile: hypertension, smoking( 1 PPD for 30 years), hyperlipidemia, sedentary life style

Lab: 1. PFT(87-5-4): mild obstructive ventilatory defect

2. EKG(87-5-4): normal sinus tachycardia, left axis deviation, right boundle branch block

3. Cardiac Echo(87-5-4): dilated LA, fair LV contractility, probable LV diastolic dysfunction, LVEF 55%

4. Cardiac cath.( 86-12-30): LAD proximal 90% stenosis, LCX 95% stenosis, RCA 70-90% stenosis


S: patient’s wife was present and appeared to be worried

O: 1. Inspection: patient breath even and unlabored with T-piece 40% FiO2, somewhat and shallow breathing

pattern noted. A-line, EKG monitor, IV via right neck, oximeter, and Foley in place

2. Vital sign: HR 100/min, BP 158/85 mmHg, CVP 10 mmHg, RR 25/min, SaO2 96%

3. Auscultation: end-expiratory crackles over LLL

4. Cough: fair in strength, loose sounding, and productive by suctioning via ET tube

5. Sputum: small-moderate amount white yellowish secretions

6. Function: in ICU routine, bed-ridden, independent in position changes

A: 1. Patient in need of chest care to prevent postoperative pulmonary complications based on the old age and

previous impaired pulmonary function test

2. Encouragement and intensive patient education may be required to increased patients activity level, modify

his risk factor, and his compliance for further cardiac rehabilitation

Problem list

1. insufficient pulmonary hygiene

2. decreased lung volume

3. decreased function and exercise endurance

STG: independent pulmonary hygiene and clear breathing sound

LTG: completion of cardiac rehabilitation phase I and introduction of phase II/III programs to reduce risk factors

and increase physical fitness

P: 1. Postural drainage/ percussion to LLL, bid(will instruct his family as home program while PT is not available)

and splinting cough training

2. deep breathing exercise( including incentive spirometer 6-10x/hr while patient is awake)

3. bilateral shoulder ROM exercise

4. Cardiac rehabilitation phase I program: cardiopulmonary function training

SPT:

109

範例一：Initial PT Evaluation Note of a Patient Receiving CABG（填空病歷）

Initial PT Evaluation Note

This -year-old patient suffered from since . He received regular

follow-up and the cardiac catheterization revealed . He was then admitted and

received on . PT started on for post operative chest care

and cardiac rehabilitation phase I program.

Risk profile:

Lab:


S:

O: 1. Inspection:

2. Vital sign: HR /min, BP mmHg, CVP mmHg, RR /min, SaO2 %

3. Auscultation:

4. Cough:

5. Sputum:

6. Function:

A:

Problem list

STG:

LTG:

P:

SPT:

110

範例一：Initial PT Evaluation Note of a Patient Receiving CABG（填寫說明）


日期

This 患者年齡-year-old性別 patient suffered from 主要症狀的描述 since 時間. He received regular follow-up

and the cardiac catheterization revealed 初步檢查結果. He was then admitted and received 手術方法或主要治療

on 日期. PT started on 日期 for post operative chest care and cardiac rehabilitation phase I program.

Risk profile: 疾病相關危險因子

Lab: 紀錄與疾病相關的實驗室檢查結果


S: 患者或主要照顧者針對疾病的主訴

O:

1. Inspection: 患者的外觀予人的感覺（如臉色蒼白、疲倦、呼吸困難等的描述）、身上的管線

2. Vital sign: Vital sign: HR休息時的心跳 bpm, BP休息時的血壓 mmHg. RR休息時的呼吸速率 breaths/min,

SaO2 休息時的血氧飽和度 %

3. Auscultation: 聽診的結果

4. Cough: 咳嗽的功能評估（包含痰咳出的難易、是否有痰咳出）

5. Sputum: 痰的量及顏色等

6. Function: 目前所可以達到的最佳功能狀態（如坐、站、並記錄是否需要他人協助）

A:

經評估後主要的問題，分點列出主要的問題。

STG: 依據評估結果擬定短期治療目標

LTG: 依據評估結果擬定長期治療目標

P: Will provide postoperative PT program as indicated, such as:

依據主要問題治療擬定目標，分項描述物理治療項目。

SPT: 實習學生簽名

111

範例二：CABGⅡ Discharge Note for a Patient receiving CABG（範本）

Discharge Note

87-5-29

This 79 year-old male patient is a case with 3-V CAD s/p CABG on 87-5-19. The postoperative course was

rather smooth. Now the patient is afebrile, breath sound clear to auscultation with little sputum expectorated, able to

walk on level ad lib and go up and down one flight of stair without any adverse signs and symptoms. (HR changed

from 76 to 84/min and BP from 140/76 to 148/80 mmHg with 2-MET walking speed). Home program has been

instructed which included breathing exercise, bilateral shoulder ROM exercise, and progressive walking program.

Contraindications for exercise and exercise-related precautions were also provided. Patient appeared to

understand all instructions and the program compliance was expected to be good.

SPT:

112

範例二：Discharge Note for a Patient receiving CABG（填空病歷）

Discharge Note

This year-old patient is a case with on . The postoperative course

was rather smooth. Now the patient is afebrile, breath sound clear to auscultation with little sputum expectorated,

able to walk on level ad lib and go up and down of stair without any adverse signs and symptoms. (HR

changed from to /min and BP from to mmHg with MET walking speed).

Home program has been instructed which included breathing exercise, bilateral shoulder ROM exercise, and

progressive walking program. Contraindications for exercise and exercise-related precautions were also provided.

Patient appeared to understand all instructions and the program compliance was expected to be good.

SPT:

113

範例二：Discharge Note for a Patient receiving CABG（填寫說明）

Discharge Note

日期

This患者年齡 year-old 性別patient is a case with診斷 on 日期. The postoperative course was rather smooth.

Now the patient is afebrile, breath sound clear to auscultation with little sputum expectorated, able to walk on level

ad lib and go up and down 幾階或幾層樓梯 of stair without any adverse signs and symptoms. (HR changed from

休息心跳 to 運動心跳/min and BP from 休息血壓 to 運動血壓 mmHg with 運動強度 MET walking speed). Home

program has been instructed which included breathing exercise, bilateral shoulder ROM exercise, and progressive

walking program. Contraindications for exercise and exercise-related precautions were also provided. Patient

appeared to understand all instructions and the program compliance was expected to be good.


114

範例三：Lung Resection Initial PT Evaluation Note of a Patient Who Will Receive Lung Resection （範本）

Initial PT Evaluation 87.1.16

The 68-year-old patient started to notice left side chest pain and dyspnea about a month ago. He then went to local

hospital for series of examination. CXR and CT revealed LUL consolidation and left hilar mass. Bronchoscopy and

biopsy revealed squamous cell carcinoma He was then referred to NTUH for further examination and treatment on

87-1-7. Left pneumonectomy was suggested and scheduled on 87-1-16. PT started today for preoperative

evaluation and orientation to the postoperative PT program.

Past Medical History:

1. Hypertension with regular control for 15 years

2. Appendectomy 10 years ago

3. Smoking 3 ppd for 10 years and quit since this Jan

Lab: 1. PFT (87-1-9): normal screening test

2. EKG (87-1-9): sinus tachycardia, nonspecific ST-T abnormalies

3. Abdomen Echo (87-1-9): negative finding

4. Bone Scan (87-1-10): negative finding


S: Worried about the upcoming surgery

O: 1. Inspection: Patient rested in bed, breathed even and unlabored, no obvious abnormal

2. Vital sign: HR 90 bpm, BP 145/80 mmHg. RR 20 breaths/min

3. Auscultation: Decreased over the left lung

4. Cough: fair in strength, dry, and non-productive at the present time

5. ROM: WML

6. Function: up in the hallway ad lib

A: Problem lists:

1. Patient is at risk for postoperative pulmonary complications and may require close monitoring and chest

physical therapy after the surgery.

2. Patient appeared to understand the orientation and instructions and will benefit from CPT after the surgery.

STG: prevent postoperative pulmonary complications

LTG: normal physical activities


1. Postural drainage/percussion to right lung and cough training when indicated

2. Segmental breathing exercise combined with chest mobility exercise

3. Incentive spirometer training: 6-10 times/hr after extubation while patient is awake

4. Reconditioning exercises

5. Left shoulder ROM and postural correction SPT:

115

範例三：Initial PT Evaluation Note of a Patient Who Will Receive Lung Resection （填空病歷）


__________

The ____-year-old patient started to notice ___________________ about __________. He then went to

local hospital for series of examination. . He was then referred to NTUH for further

examination and treatment on______________ was suggested and scheduled on ____________. PT started

today for _________________.


Lab:


S:

O:

1. Inspection:

2. Vital sign: HR ______ bpm, BP __________ mmHg, RR breaths/min

3. Auscultation:

4. Cough:

5. ROM:

6. Function:

A: Problem lists:

STG:

LTG:


SPT __________

116

範例三：Initial PT Evaluation Note of a Patient Who Will Receive Lung Resection（填寫說明）


日期

The患者年齡-year-old 性別 patient started to notice主要症狀的描述以及症狀已持續的時間. He then went to local

hospital for series of examination. 簡述初步的檢查結果. He was then referred to NTUH for further examination

and treatment on 住院日期. 手術方法或主要治療項目 was suggested and scheduled on接受手術方法或主要治療

項目的日期. PT started today for主要物理治療介入的項目.

Past Medical History: 過去主要病史的記錄（如 Hypertension、DM等）

並記錄是否有不良健康嗜好（如抽煙、喝酒、嚼檳榔等）

Lab: 記錄與疾病相關的實驗室檢查結果（如 PFT、EKG等）

Physical Examination: S: 患者或主要照顧者針對疾病的主訴

O: 1. Inspection:患者的外觀予人的感覺（如臉色蒼白、疲倦、呼吸困難等的描述）

2. Vital sign: HR休息時的心跳 bpm, BP休息時的血壓 mmHg. RR休息時的呼吸速率 breaths/min

3. Auscultation:聽診的結果

4. Cough:咳嗽的功能評估（包含痰咳出的難易、是否有痰咳出、痰的量及顏色等）

5. ROM:上下肢的關節活動度

6. Function:目前所可以達到的最佳功能狀態（如坐、站、並記錄是否需要他人協助）

A: 經評估後主要的問題，分點列出主要的問題。



P:

Will provide postoperative PT program as indicated, such as:

依據主要問題級治療擬定目標，分項描述物理治療項目。

SPT實習學生簽名

117

範例四：Cardiac Rehabiltation Initial PT Evaluation Note of a Patient Enrolled for Cardiac Rehabilitation（範本）

Initial PT Evaluation Note 90-12-10

The 65-year-old male patient suffered from sudden onset of consciousness loss and chest tightness on

90-7-17. The consciousness recovered spontaneously in about 30 secs. EKG and cardiac echo revealed old MI and

LV aneurysm. Cardiac catherization was performed on 90-7-30 which showed 50% distal stenosis of LM,

mid-portion total occlusion of LAD, multiple 70-90% stenosis of LCX, and mid-RCA 90% stenosis and distal portion

90% stenosis. He received CABG with LIMA and SVG on 90-8-6 and 1st graded maximal exercise test on 91-12-2.

PT started on 90-12-10 for cardiac rehabilitation program.

Risk profile: patient denies DM, hypertension, and hyperlipidemia, smoking(2PPD for 40 years) quit since this july

Lab: 1. Holter EKG (90-7-21): basically sinus rhythm, occasional APC and VPC

2. Radionuclide angiography with MUGA blood pool technique (90-7-22): LVEF= 32%

3. Cardiac Echo(90-8-6): LV apical dyskinesia

4. GXT(90-12-2): AT: 50Watt, HR: 113 bpm, VO2: 924ml/min, 69% VO2 max

Peak: 90Watt, HR: 142 bpm, VO2: 1338 ml/min, 73% of predicted

Significant ST-T displacement over inferior leads during exercise;

Stopped exercise because of leg fatigue and buttock pain


S: walk with wife for about 20 min on daily basis since discharge in Aug.

O:

1. Inspection: patient breath even and unlabored, moderate nourished and mild overweight noted

2. Vital sign: HR 82/min, BP 120/70 mmHg, RR 16/min, SaO2 96%

3. Auscultation: no basilar rales, no S3 or S4 heard

4. Cough: Voluntary and nonproductive

5. Flexibility: WNL

6. Muscle strength: WNL

7. Function: independent, no adverse sign or symptoms noted during daily activities

8. Exercise response: 30 Watt biking 10 minutes, HR to 92/min, BP to 130/72 mmHg; 45 Watt biking 10 minutes, HR to 106/min, BP to 132/74 mmHg; finally 30 Watt biking 5 minutes, HR to 98/min, BP to 110/70 mmHg. After resting 5 minutes, HR to 80/min, BP to 118/84 mmHg. No adverse sign or symptoms noted during or after exercise. RPE 12 reported during the last minute of 45 Watt

A: 1. Normal exercise response

2. High risk

3. Good compliance expected

4. More patient education required, such as monitoring own pulse etc.

Problem list: Relatively decreased cardiopulmonary fitness compared to normal subjects

Goals: to improve his cardiopulmonary fitness and to reduce risk factors of CAD

P: 1. Bike exercise training in PT department with EKG monitoring 3×/WK

2. Home exercise programs: walking program and upper-limb exercise

SPT:

118

範例四：Initial PT Evaluation Note of a Patient Enrolled for Cardiac Rehabilitation（填空病歷）


The -year-old patient suffered from on . EKG and cardiac echo revealed

. Cardiac catherization was performed on which showed

. The patient received CABG with on and 1st graded maximal exercise test

on . PT started on for cardiac rehabilitation program.

Risk profile:

Lab: 1. EKG ( ):

2. Cardiac Echo( ):

3. GXT( ):


S:

O: 1. Inspection:

2. Vital sign: HR /min, BP mmHg, RR /min, SaO2 %

3. Auscultation:

4. Cough:

5. Flexibility:

6. Muscle strength:

7. Function:

8. Exercise response:

A:

Problem list:

Goals:

P:

SPT:

119

範例四：Initial PT Evaluation Note of a Patient Enrolled for Cardiac Rehabilitation（填寫說明）


日期

The 患者年齡-year-old 性別 patient suffered from主要症狀的描述 on 時間 . EKG and cardiac echo

revealed 初步檢查結果. Cardiac catherization was performed on 日期 which showed 檢查結果. The patient

received CABG with 手術內容與方法 on 日期 and 1st graded maximal exercise test on日期. PT started on日期

for cardiac rehabilitation program.

Risk profile: 疾病相關危險因子

Lab: 1. EKG ( 日期): 檢查結果

2. Cardiac Echo(日期): 檢查結果

3. GXT(日期): 檢查結果，應列出 AT值、最大攝氧量、停止運動測試的原因


S: 患者或主要照顧者針對疾病的主訴

O: 1. Inspection: 患者的外觀予人的感覺（如臉色蒼白、疲倦、呼吸困難等的描述）

2. Vital sign: HR休息時的心跳 bpm, BP休息時的血壓 mmHg. RR休息時的呼吸速率 breaths/min, SaO2 休息

時的血氧飽和度 %

3. Auscultation: 聽診的結果

4. Cough: 咳嗽的功能評估（包含痰咳出的難易、是否有痰咳出）

5. Flexibility: 描述四肢軀幹的柔軟度

6. Muscle strength: 評估肌力

7.Function: 描述日常生活功能，是否需協助，有無特殊症狀

8. Exercise response: 紀錄說明患者在接受運動訓練時之心跳血壓反應


Goals: 依據評估結果擬定治療目標

P: 依據主要問題治療擬定目標，分項描述物理治療項目。


120

範例五：COPD

Initial PT Evaluation Note of a COPD Patient （範本） Initial PT Evaluation Note

87-5-12

The 72 year-old male patient had diagnosis of COPD 20 years ago. He suffered from acute onset of severe

dyspnea since 87-4-19. His symptoms exacerbated and he was sent to our ER where CXR showed left

pneumothorax. Chest tube was inserted on 87-4-21 and pleurodesis was done on 87-5-5 and 87-5-7. PT was

consulted for breathing retraining and started on 87-5-12.


1. Hypertension

2. Smoking 1 ppd for 30 years

3. Hyperlipidemia

Lab: 1. ABG (87-5-4): pH: 7.40、PaCO2:52 mmHg、PaO2: 65 mmHg

2. CXR (87-5-8): emphysematous chantes, no pneymothorax

3. EKG (87-5-4): sinus tachycardia, nospecific ST-T abnormalities

4. Sputum culture (87-5-6): acinetobactor baumannii 1 +, yeast-like organism 3 +, enterobactor cloacae 1 +


S: Patient stated that he lived on 2nd floor, did ADL independently, limited to his apartment, and walked to bathroom

by using handrails with occasional oxygen supplement, but he has been bed ridden since admission. Patient’s

family complained his poor compliance to medicine and bad tempers.

O: 1. Inspection: Clear consciousness with fair cooperation somewhat kyphoscoliosis and severe barrel

chest, patient breathe with much accessory muscle use (2N1C1D), no abdominal asynchrony noted

but mild-moderate increased work of breathing at rest, oxygen therapy (1 L/min) via nasal prongs

prn.

2. Vital sign: HR 100 bpm, BP 128/86 mmHg. RR 24 breaths/min

3. Auscultation: generally decreased

4. Cough: fair in strength, loose sounding, and productive

5. Sputum: small amount white yellowish secretions

6. Function: bed-ridden, patient was able to assume to standing position slowly with guidance and minimal

assistance for the 1st time since admission, RR changed to 32 breaths/min without much complaints, he

then walked 5 meters by propelling the wheelchair and RR changed to 40 breaths/min with complaints of

severe dyspnea.

A: Patient may benefit from better pulmonary hygiene by improving his cough techniques, breathing retraining,

and exercise training with supplemental oxygen.

Problem list:

1. Insufficient pulmonary hygiene

2. Decreased breathing efficiency

121

3. Decreased function and exercise endurance

STG: Improved pulmonary hygiene and breathing efficiency

LTG: Pulmonary rehabilitated with less dyspnea and better exercise or walking endurance.

P:

1. Postural drainage/percussion to bilateral lower lobes qd-bid (instructed to the family) and huff-cough

training from lower lung volume

2. Diaphragmatic pursed-lip breathing exercise with abdominal augmentation and 1:2 inspiration to

expiration ratio

3. Function training and progressive interval-walking program

4. Recommend pulmonary rehabilitation program from OPD

SPT:

122

範例五：Initial PT Evaluation Note of a COPD Patient （填空病歷） Initial PT Evaluation Note

The year-old patient had diagnosis of . He suffered from since

. His symptoms exacerbated and he was sent to our ER where CXR showed .

PT was consulted for and started on .


Lab:


S: .

O:

1. Inspection:. .

2. Vital sign: HR bpm, BP mmHg. RR breaths/min

3. Auscultation: .

4. Cough: .

5. Sputum: .

6. Function:

A:

Problem list:

STG:

LTG:

P:

SPT _______________

123

範例五：Initial PT Evaluation Note of a COPD Patient （填寫說明） Initial PT Evaluation Note

日期

The患者年齡 year-old 性別 patient had diagnosis of 主要診斷以及此診斷已持續時間. He suffered from主要臨

床症狀 since主要臨床症狀開始出現的時間. His symptoms exacerbated and he was sent to our ER where CXR

showed主要的檢查結果. 臨床上針對此次病發所已經做過的治療和治療日期. PT was consulted for主要轉介物理治

療的原因 and started on日期.

Past Medical History: 過去主要病史的記錄（如 Hypertension、DM等）

並記錄是否有不良健康嗜好（如抽煙、喝酒、嚼檳榔等）

Lab: 記錄與此次疾病相關的實驗室檢查結果（如 ABG、CXR、Sputum culture等）


S: 患者或主要照顧者針對疾病的主訴.

O: 1. Inspection:患者的外觀予人的感覺（如臉色蒼白、疲倦、呼吸困難等的描述）

2. Vital sign: HR休息時的心跳 bpm, BP休息時的血壓 mmHg. RR休息時的呼吸次數 breaths/min

3. Auscultation:聽診的結果

4. Cough:咳嗽的功能評估（如是否可自咳出痰）

5. Sputum:自咳或抽痰出的量及顏色

6. Function:目前所可以達到的最佳功能狀態（如坐、站、並記錄是否需要他人協助）




P: 依據主要問題級治療擬定目標，分項描述物理治療項目。

SPT實習學生簽名

ꑑꑀꅂ꽦뻺껦ꚡ뭐뵤ꖻ - pt.ntu.edu.t · pdf file44 ꑑꑀꅂ꽦뻺껦ꚡ뭐뵤ꖻ...

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