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8/4/2019 Documentation Ver 2

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Introduction

to SEMINAR



Importance of a Document serves as a legal documentmeans of communication with other health

professionals basis of decision making concerning reimbursements basis for dischargemethod for dischargemethod of structuring thinking for problem solving

for quality assurance purposes potential research material



Types of Notes Initial Note

Written after the initial PT treatment & assessment

Assessment of PT is different from the physician’s initialevaluation

Sets a baseline data, determines the problems, and

guide for setting both short-term and long term goals



Interim/ Progress notes

Written periodically

Reports the result of reassessment

Takes note of progression or regression of patient

status

Takes note of patient’s response to treatment



Endorsement Note

Note that allows or endorses a patient’s treatment to

be done by other therapist

Discharge note

Written at the time therapy is discontinued

Should state the condition and progress of the patient

during the whole course of therapy



Incident report Notes of any untoward incident or accident related to

one’s function as a therapist



WHAT IS THE BASIS FORPRIORITIZING?

The problem that is most distressing to the patient (usually the chief complaint).

The problem that leads to the other problems suchthat solving it will automatically solve or control theother problems.

The problem that will require only PT and will benefita lot from it (this may be arranged in decreasingorder of success rate); in other words the other problems, although included in the list will simplyrequire referral to other disciplines.



Goals: Rehabilitation Goals – functional performance we expect

the patient to achieve as a result of therapy

Needs for Goals:

For effective treatment planning

Goals provide framework for PT program

To measure effectiveness of management

Assist in monitoring cost effectiveness

To communicate to other health workers



Components of goals:Audience: refers to the patient who shall

be exhibiting the skills set forth as our goal

Behavior: skill or task to be performed bythe patient always a verbCondition: circumstance wherein patient

would perform expected behavior e.g. cmin. assist +1

Degree: an objective criteria which mustbe realistic objective, observable, with atime span expressed in terms of function



Long term Goal (LTG) Final product to be achieved by PT intervention

Dependent on:

Prognosis

Stage of recoveryAge, job, home setting

Patient compliance

Sensation

Cognitive skills Insurance coverage



Pt. will independently perform transfers from w/c tocar within 4 wks.

Pt. will ambulate with bilateral KAFO and crutchesusing a swing-through gait and close supervision for

50 ft within 5 weeks. Pt. will maintain static balance in sitting with

centered, symmetrical weight-bearing and noupper extremity support or loss of balance for up to

5 minutes within 4 weeks. Pt. will sequence a three- to five-step routine task

with minimum assistance within 5 weeks.



Short term Goal (STG)

Interim steps along the way to achieve LTG

Have a time span for achievement



Pt. will ↑ strength in sh. depressor mm and elbow ext.

mm in (B) UE from good to normal within 3 weeks.

Pt. will ↑ ROM 10° in knee ext. bilaterally to WNL

within 3 weeks.

Pt. will be independent in the application of LEorthoses within 1 week.

Pt. and family will recognize personal andenvironmental factors associated with falls during

ambulation within 2 weeks



Problems to be avoided in writing

goals: Vague goals

Inconsistency between LTG & STG

Incorrect focus (focus on patient, not on therapist)



Plan

Describes the treatment program patient

will receive

Final step in the planning process

Based on S, O, & A

Includes modalities, procedures and

exercises



Format in writing PT Mx

Modalities:

What modality, where, dosage, rationale

Exercise:

Type, extremity, repetitions, position,

modifications, amount of resistance

Ambulation

Type of gait pattern, device, surface,distance, level of assistance



PT INITIAL EVALUATION

Diagnosis: Central Cord Syndrome (Chip Fx of C3-C5. compression FxT8 and T12, complete oblique Fx of 2nd and 3rd R MCP

HPI:

This is a case of R.D., a 20 y/o r handed male px fromSalawag Dasma, Cavite. Who is non-diabetic, occasional alcoholicdrinker and cigarette smoker. Who brought here at OM due to fall.

Present condition starter last May 10, 1991 when the patient ataround 1:30 PM climbing a coconut tree to get some leaves,unfortunately the leaves caught up a live wire and the Px gotelectrocuted which causes him to fall from it. The height is about 13ft. and he landed hitting his back first and R hand which causes hima Chip Fx of C3-C5, compression Fx of T8-T12, complete oblique Fx of

2nd and 3rd R MCP. He claimed that he lost consciousness at about 5mins. When he gains consciousness he was already inside the jeepwhich brought him here at SJDH together c his friends. The patientclaimed of pan all over his body and was not able to move his body.



IMPROVED CLINICAL HISTORY Present condition started 13 days PTIE when pt fell from a height of

13 feet after touching a live wire and experienced transient loss ofconsciousness, intense body pain and inability to move all extremities.

Upon admission (date), pt was admitted with a diagnosis ofCompression Fracture T8 & T12, chip Fracture C3-5 secondary to fall;Central Cord Syndrome; concomitant Oblique Fracture 2nd and 3rd Metacarpal, Right. Neurologic evaluation showed complete flaccidquadriplegia C5, sensory deficits C6, neurogenic bladder. No electrical

burns noted. No respiratory distress. Patient was then immobilized withGardiner Tongs and right hand and wrist immobilized with a posterior POPsplint

10 days PTIE (3rd Hospital Day), there was noted progressive returnof sensation in a cephalad direction and ascending motor recovery andreturn of bowel and bladder sensation

7 days PTIE (6th Hospital Day), pt was assessed to have fair to good

(B) LE strength and complete sensory recovery BUE/BLE. There wasbeginning motor recovery noted in (B)UE. Pt effectively expectoratessecretions with no respiratory distress.

At present (13th Hospital Day), pt is referred to RehabilitationMedicine for orthotic prescription, neck and mobilization. Pt is stillimmobilized on cervical tongs and claims there is continued gradualmotor recovery in the BLE and proximal UE etc….



PT INITIAL EVALUATION

Diagnosis: Degenerative OA of Cervical and Lumbar SpineChief Complaint: Pain on cervical and low back area PS 2-3/10

HPI:

Present condition started 2 months PTC when Px experienced persistent

pain over the nape and low back area radiating to the RUE c a score of 6/10.

Pain on the nape was said to be aggravated by extending the neck and low

back pain was aggravated by flexing the trunk. Pain was characterized as deepand throbbing. Px experienced numbness on the R hand and had found difficulty

in writing and holding objects, however, other ADL were not affected. A tingling

sensation over the dorsum of the hand and dorsal part of the forearm was felt. Px

was advised by the family doctor to seek rehabilitation and the therapy opted to

be done at SJDH. At present, pain is still experienced c the same characteristic

but c less intensity PS 3/10. Px tries to avoid writing because the R hand easily get

strained, and finds difficulty in doing laundry. No medications are being taken for

arthritis but takes in Vit. B12 regularly.



IMPROVED CLINICAL HISTORY Present condition started 2 months PTC when pt experienced 6/10

acute onset, nape pain radiating to RUE with distal paresthesia andnumbness upon waking up. Pt claimed that sleeping position was pronewith neck rotated. Px’s condition spontaneously improved after 5 days smedication but avoided pain-inducing neck positions. Since then wouldhave recurrent, tolerable nape and lumbosacral pain with no functionalimpairment or limitations.

1 week PTC, there was persistent 3/10, insidious onset, vague acheover nape and upper back area occasionally radiating to RUE with distalparesthesia and numbness. Pain increases to 5-7/10 after 3-4 hours ofworking as a drafter with difficulty in holding pens and writing/ drawing;temporarily relieved with Mefenamic Acid 500 mg taken QID. Pt has

difficulty in sleeping due to pain and feels tired upon waking up. Pt wasunable to complete household chores after work due to pain. Pt soughtmedical consult and was subsequently referred for PT. No similar worseningin the lumbosacral pain which has remained as an occasional, localized,tolerable vague ache.



THE DISCHARGE SUMMARY Should contain the following information:

pertinent demographic data brief summary of the database (this usually just emphasizes on the

pertinent or positive findings) the problems identified in the patient the corresponding treatment the clinical course during the period of therapy specifying:

the number of treatment sessions and duration of program

a summary of the progress of the patient

pertinent changes in the treatment

outcome of the program discharge PE – this means that a therapist should always do a

repeat PE on the patient just before his discharge and not basethe report on the previous treatment session with the patient



ENDORSEMENT NOTES

Should contain a summary of the following:

pertinent demographic data

summary of the database focusing on pertinent findings problems identified in the patient (although if a problem

list form is present then you may just ask the incoming PTto refer to it)

the corresponding treatment plan

summary of the clinical course of the patient similar tothe discharge summary

you latest physical examination findings of the patient

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