Documentation in Physical Therapy

PART II

Documentation in Physical Therapy Juanito C. Lim III, PTRP

Introduction to Physical Therapy Documentation • Purposes of Documentation – All healthcare professionals document their findings for several reasons: • Notes record what the therapist does to manage the individual patient‟s case. – All medical records are legal documents

• Documentation is a method of communicating with the patient‟s physician and other healthcare professionals, including other therapists and therapist assistants. – Communication through documentation provides consistency between the services provided by various healthcare professionals

• Third-party payers make decisions about reimbursement based on therapy notes. – Reimbursement decisions can be greatly influenced by the quality and completeness of documentation

• Within the facility, patient charts are reviewed. – Discharge or further intervention decisions are made based, in part, on the documentation written by healthcare professionals

• Proper documentation helps the therapist to organize the thought processes involved in patient care. – Documentation structures thinking for problem solving

• Documentation can be used for quality assurance and improvement purposes. – Certain criteria are set to indicate whether quality care is occurring

• Documentation can be used for research. – Data from documentation can be gathered and conclusions can be drawn

– Documentation is an integral part of the patient care process as the assessment or treatment of the patient.

Relationship of Documentation to the Decision-making Process Decision-making in PT  Elements of Patient/Client Management  PT Documentation

• Elements of Patient/Client Management – Examination – Evaluation – Diagnosis – Prognosis (including Plan of Care) – Intervention

• During an initial session with a patient, the process of assessment and decisionmaking occurs in the following manner: – The therapist reads the patient‟s chart (medical record) or referral (if either is available). • Data gathered here are under Identifying Data/Demographics

– The therapist then interviews the patient. • Data gathered here are under Subjective

– From the information gathered from the medical record and the patient, the therapist plans the objective measurements to be performed. Then the planned measurements are completed. • Data gathered here are under Objective

– The therapist interprets the information recorded and identifies factors that are not within normal limits for people in the same age range as the patient. From these factors, the therapist formulates a list of the patient‟s problems, including functional limitations, impairments, and disabilities. • Data here are placed under Assessment, specifically Problem List

– The therapist formulates impressions of the patient‟s problems and conditions. • Data here are placed under Assessment, specifically Summary/Impression/Prognosis

– The therapist and the patient together establish outcomes that correspond to the patient‟s functional limitations, impairments, or disabilities. • Data here are placed under Assessment, specifically Long Term Goals/Functional Outcomes/Expected Outcomes

– The therapist and the patient then consider what can be achieved within a short period of time (anticipated goals). • Data here are placed under Assessment, specifically Short Term Goals/Anticipated Goals

– The therapist outlines a treatment plan to achieve them. • Data here are placed under Plan/Plan of Care/Interventions

Writing in a Medical Record • The writing style used in medical records differs from the style most students are accustomed to using when writing papers, reports, et al.

• Characteristics of Good Documentation in a Medical Record: – ORGANIZED • All entries in a chart must be arranged in such a way that facilitates use by other health personnel in the same facility • In an organized chart: – All entries are in their proper location. – The sheets are properly arranged. – The data is recorded as a sequence of events.

• Each facility has its own policies on charting and recording, so familiarize yourself with the policies in every new facility

– CHRONOLOGICALLY ARRANGED • All entries must have a date and time • Has legal implications • Avoids unnecessary duplication of services and unnecessary queries

– AUTOGRAPHED • All entries must have the printed name and signature of the person who evaluated/treated the patient at the end of the written report/prescription

– FEW ABBREVIATIONS • Use only internationally accepted abbreviations and use them as infrequently as possible • Implications if not followed: – May lead to misinterpretation and confusion – Other users of the chart may not be familiar with the abbreviations used

– TRUE RECORD OF ACTUAL OBSERVATIONS/INFORMATION • All entries must be those that were actually obtained/elicited • Entries must not be copied from other health professionals‟ documentation but may be recorded only if therapist repeats the test and confirms the given finding

– PROMPTLY RECORDED • All entries must be recorded immediately after obtaining them or after treatment • If not recorded promptly, other health professionals may have written notes ahead of your note so chart does not become chronologically arranged

– BRIEF BUT COMPLETE, RELEVANT, AND SENSIBLE • Time is valuable but this does not be used as an excuse to shortcut procedures, not to write legibly, use plenty of abbreviations, and/or edit the more important data

– LEGIBLE • Self-explanatory

• Basic Guidelines in Charting/Recording – Maintain an organized and properly arranged record. – Promptly record all findings. – Put the date and time of evaluation and/or treatment and maintain a chronologically arranged record. – Minimize use of abbreviations and use only universally accepted abbreviations.

– Record only information that was actually observed and/or elicited. – Always acknowledge an entry by printing your name and affixing your signature above the printed name. – Do not leave spaces between entries to avoid tampering. – Never change an entry made by another health profession nor tamper with any of the data contained in a chart.

– Write legibly. – Be specific and direct to the point.

Some Specifics Regarding Writing in a Medical Record • Punctuation – Hyphen (-) • Can be confused with „minus sign‟ or „negative‟ • Exception only if used instead of the word „through‟ • Example: 0 - 45

– Semicolon (;) • Used instead of overusing „states‟ in the Subjective portion to connect related statements • Example: Instead of: States position of comfort for sleep is on ® side. States pain does not awaken pt. at night. BETTER: States position of comfort for sleep is on ® side; pain does not awaken pt. at night.

– Colon (:) • Can be used instead of „is‟ • Example: Instead of: AROM ® shoulder is 0-90 BETTER: AROM ® shoulder: 0-90.

• Correcting Errors – Never use correction fluid!!! – Charting errors should be corrected by drawing a single line through the error, write „(error)‟ above the mistake, date it, and initial it – Example: (error) JMP 11/17/03 ---------some min+1 assist.

• Signing Your Notes – All notes should be signed with your legal signature (your last name and legal first name or initials) – No nicknames should be used – Initials should follow your name indicating your status/designation

– Example:

J Phoenix Jason Phoenix, SPT

• Referring to Yourself – Notes discuss the patient and not the therapist – If a therapist must make reference to himself/herself, reference should be made in the third person – Example: Pt. states therapist should be putting his shoes on for him like his family does at home.

• Spaces, Blanks or Empty Lines – Should not be left between one entry and another, nor be left within a single entry – Could become areas in which another person could falsify information already charted

• Writing Orders in a Chart – When a physician gives an order to a therapist, the therapist is responsible for writing it in the chart

– Standard format: date/time/order v.o. physician‟s name/therapist‟s signature, status/designation OR date/time/order verbal order by physician‟s name/therapist‟s signature, status/designation

– Example: 11-17-03/11:45/Pt. may ambulate with Bil. axillary crutches

JLim lll v.o. Dr. Lim/Juanito Lim III, PTRP

• Using Abbreviations and Medical Terminologies – Abbreviations: • Minimize use of abbreviations and use only universally accepted abbreviations • Familiarize yourself with a facility‟s approved abbreviations

– Medical Terminology: • Most medical terms have Latin-based prefixes, suffixes, or roots • Refer to a medical encyclopedia/dictionary when in doubt

History of Development of Documentation • The SOAP Note Format – SOAP stands for: S – Subjective O – Objective A – Assessment P – Plan

– Introduced by Dr. Lawrence Weed in 1955 as a part of a system organizing the medical record called the problem-oriented medical record (POMR)

– Has a patient data base and a list of patient problems in the front of the chart, and each healthcare practitioner writes a separate SOAP note to address each of the patient‟s problems • i.e. one (1) SOAP note for each problem

– Components: • Patient Database • Problem List • SOAP Notes

– Disadvantage: • It is very tedious and would be very difficult to apply in centers where healthcare professionals see more than ten (10) patients a day

– Many facilities never use the POMR – Widespread use of the SOAP note format is one clear contribution – Each professional field and each facility has its own variation of the SOAP note format

• Functional Outcomes Recording – Adapted from the traditional SOAP note format – Emphasizes and discusses the patient‟s functional status and sets goals and treatment to improve function only

Trends in Physical Therapy Documentation • Medicare Forms – In the United States, Medicare has developed several forms (700, 701, 702) in an attempt to gather consistent data needed to make decisions about whether the patient‟s condition and treatment qualifies for Medicare coverage. – Before these forms were developed, reviewers for Medicare were receiving poor quality patient notes.

– Data seen in Medicare forms are: • Demographic data • Basic medical data • Data that should already be contained in a wellwritten SOAP note like: – – – – – –

Functional status prior to treatment Current functional status Long term goals Short term goals (listed as monthly goals) Treatment plan Justification for treatment

• Documentation Forms – This type of documentation is used in many clinics. Some reasons for this are: • Decreasing the amount of writing by the therapist/assistant • Increasing the efficiency of the therapist/assistant in documenting patient care

• Increasing the consistency of documentation (and thus fulfilling certain quality assurance or legal/risk management requirements) by building certain components into a note, such as whether the patient is given a home program and his/her level of independence in performing the home program • Making the data gathered for outcomes studies more consistent • Making functional information easier to read by all parties who use the information

– Forms are usually individualized to fit the needs of the individual healthcare institution and its patient population.

– Types of Documentation Forms • • • • •

Flow sheets Initial assessment / discharge note forms Interim / discharge note forms One-visit-only documentation forms Supplemental forms – These forms are to be attached to initial, interim, or discharge forms and often have specialized tests or scales that are only needed with certain types of patients.

– Development of Documentation Forms • When designing a form, a good place to start is by watching clinicians practice wherein items to be included in the form are those that are commonly assessed by the therapist. Other additions to the forms can be obtained by asking staff members to use the forms and give feedback to those designing the forms. • When beginning to use a new form, it is important for the therapist / assistant to give himself / herself time to adapt to the use of the form to improve efficiency in the use of the form.

• The most efficient use of a form is to complete a form, or at least begin its completion, while seeing the patient. Subjective and objective findings may be written directly on the form, if permissible, to save time. • If a form is limited, specifically if an item is missing from the form, the therapist / assistant must find a place to write the missing item if it is relevant to the patient‟s function. • Forms should also be revised on a regular basis to meet the needs of good clinical practice.

• When developing a form, the following should be considered: – Do not start from scratch. Revise a form from another facility, with permission, using the other facility‟s form as the basis for the present facility‟s form. – After a draft version has been made, those who use and read the forms must be asked what it is supposed to do for all parties involved. – Communicate with all parties involved when developing forms. If the form is to be useful, everyone must know how to use the form, both writing on the form and reading the form. – Subjective and objective items commonly assessed by the staff must be included.

– If a standard scale, test, or definition of measurement is used by all staff to measure or document a certain characteristic of the patient or a certain facet of patient care, a checklist may be faster in documenting patient care. – Checklists can save therapist time and add speed in documentation. – If any sort of checklists are used in note forms, try to make the checklists consistent or similar from one form to another to save confusion and unnecessary staff reorientation time. – Frequently leave space for very brief comments or descriptions.

– Unless the form is created with a very specific patient population in mind, allow for a general assessment of the patient. – If there are no standardized methods of documenting the information derived from your assessment of the patient, allow room for writing. – Forms will influence practice, so make sure to include items that are believed essential to practice. – If the staff has been writing SOAP notes, transition for the staff will be easier if a SOAP format is followed because SOAP is a problem-solving format and documenting using this format on a form assists the staffing problem solving.

– Function should still be stated first in the subjective and objective portions of the note form, just as when writing a SOAP note.

• Computerized Documentation Programs – Computerized documentation is still in the stages of development. Some facilities have a well-developed program that is tailored to the needs of that facility.

– Advantages of Computerized Documentation over Paper-based Documentation: • Information placed in a paper-based documentation may be limited due to limited space allowed for information in a form while information that may be placed in a computerized document is not limited. • Computers can also have all of the possible tests and measurements available, so the therapist is not limited by the tests and measurements available on a given form.

– Some Features That Have Been Developed or are In Stages of Development That Will Make Computers Even Easier to Use in the Future: • Data can be entered by making choices and simply touching a stylus to the screen. – This makes data entry more consistent and does not require keyboard competence.

• Data can be printed in a variety of formats. – Since computerized documentation programs utilize data in a database form, required data in different forms may be directly placed in corresponding spaces. – It could also allow the therapist to choose certain functional or relevant data to send to the patient‟s physician or other referral source.

• The medical record can be retrieved and notes written at the patient‟s bedside. – Some healthcare facilities have computers located in every patient‟s room or between every two rooms. – The therapist may be able to use a notebook computer with him / her that contains and / or can access the patient‟s medical record and rehab information for all the patients the therapist treats.

• All documentation can be completed at bedside. – Even outpatient and home healthcare therapists will be able to have a notebook computer with them and be able to transmit / receive information via modem or other electronic means.

• Handwriting recognition is a feature that will be developed more in the next few years. – This will enable the therapist to enter extra notes and information as needed.

• Voice recognition is a feature that will also be developed more in the next few years. – This could completely change methods of data entry, although some caution must be taken in the use of voiceactivated methodology while at the patient‟s bedside.

• Charging will be able to be done by the therapist immediately upon completing the patient‟s treatment and while he / she completes other computerized documentation (and the computer may remind the therapist to charge the patient.) – Computerized charging systems exist in many clinics today. Moving the charging to the patient‟s bedside, along with all other documentation functions, will greatly increase therapist efficiency and relieve the repetition in documentation that some therapists experience today.

– Items to Consider When Looking at Computerized Documentation Systems: • It is important to consider the needs of the therapists at their individual practice sites. – A system should be flexible enough to fulfill the needs of the therapist at the individual practice site; otherwise, the system is not worthwhile.

• Computerized documentation systems vary in their mobility, weight, flexibility, ease of use, speed of data entry, and speed of the hardware. – All of these factors must be considered when purchasing or developing a computerized system.

• Training time must be taken into consideration when you discuss the cost of a computerized documentation system. – A system that requires extensive training must also save much time I order to be cost effective.

• Technology is only worthwhile if it makes the therapist‟s task of documentation easier and allows him / her to do something he / she could not do without the technology. – For example, the time spent documenting should be decreased, and spelling errors or obvious errors in the recording of data should be pointed out to the therapist automatically for the purpose of immediate correction.

• The willingness, availability, and cost of programmers to customize the system to the individual facility‟s needs should be investigated before making a commitment to a computerized documentation system.

Obtaining and Documenting Subjective Content • Introduction to the Interviewing Process and Reviewing the Medical Record – Interviewing is an important skill for the clinician to learn. – Generally agreed that 80% of the information needed to clarify the cause of symptoms is contained within the subjective examination. – Begin the interview by determining the patient‟s chief complaint (C/C:).

– Usually is a symptomatic description of the patient (i.e., subjective sensations reported, such as fatigue, dizziness, night sweats, fever). – The interview, especially in the subjective data, may also reveal contraindications to physical therapy treatment or indications for the kind of treatment that is more likely to be effective.

• Example: – A patient examined by a physical therapist last year found that ultrasound was the most effective method for providing long-term relief of symptoms.

– Questioning the patient may also assist the physical therapist in determining the injury stage. • Guides the clinician in providing appropriate treatment in the injury stage: – Acute injury - symptomatic relief. – Chronic injury - more aggressive treatment. – Sub-acute injury - combination of the above methods.

– Interviewing the patient and reviewing the patient‟s medical record will help the physical therapist to determine the location and potential significance of any symptom (including pain). – The interview format provides detailed information regarding the frequency, duration, intensity, length, breadth, depth, and anatomic relation as these relate to the patient‟s chief complaint.

– The physical therapist will later correlate this information with the objective findings of the examination to rule out possible systemic origins of symptoms. – The information obtained from the interview guides the physical therapist in either referring the patient to a physician or in treating the patient in a clinic.

• Interviewing Techniques – An organized interview format assists the physical therapist in obtaining a complete and accurate database. – Using the same outline with each patient ensures that all pertinent information related to previous medical history and current medical problem(s) is included. • This information is especially important when correlating the subjective data with objective findings from the physical examination.

– Open-ended Questions • Questions that elicit more than a one-word response. • Example: – „Tell me why you are here.‟

• Advantage: can prevent a false-positive or falsenegative response that otherwise would be elicited by a closed-ended question.

• Disadvantage: may allow the patient to control the interview through an organ recital. – Organ Recital – a patient provides detailed information regarding ALL previously experienced illnesses and symptoms that may or may not be related to the current problem

– Example “Organ Recital”: » „The pain in my hip started 12 years ago when I was a corpsman in the navy standing on my feet 10 hours a day. It seems to bother me most when I am having premenstrual symptoms, such as food cravings or depression. My left leg is longer than my right leg, and my hip hurts when the scars from by bunionectomy ache. This pain occurs with any changes in the weather. I have a bleeding ulcer that bothers me, and the pain keeps me awake at night. I dislocated my shoulder 2 years ago, but I can lift weights now without any problems.‟

– Closed-ended Questions • Require only a „yes‟ or „no‟ answer. • Example: – „Do you have any pain after lying in bed all night?‟

• Disadvantages: – Tend to be more impersonal and may set an impersonal tone for the relationship between the patient and the physical therapist. – Limited by the restrictive nature of the information received so that the patient may only respond to the category in question and may omit vital, but seemingly unrelated, information. – May elicit false-positive or false-negative responses that develop from the patient‟s attempt to pleas the health care provider or to comply with what the patient believes is the correct response or expectation.

– Funnel Technique/Funnel Sequence • Begin with one or two open-ended questions, interrupt patient with a polite statement if or when patient starts to do an „organ recital‟, then start asking follow-up questions. • Example polite statement for interrupting patient: – „I‟m beginning to get an idea of the nature of your problem. Now I would like to obtain some more specific information.‟

• Follow-up Questions – Are usually closed-ended questions that characterize symptoms more clearly.

• Advantages: – Can potentially elicit more information in a relatively short (5 – 15 minute) period than a steady stream of closedended questions. – Can establish an effective forum for trust between the patient and physical therapist.

• Example of funnel sequence: – Beginning (open-ended) question: » „How does rest affect the pain or symptoms?‟ – Follow-up questions: » „Are your symptoms aggravated or relieved by any activities?‟ » „If yes, what?‟ » „How has this affected your daily life at work or at home?‟ » „How has this problem affected your ability to care for yourself without assistance (e.g., dress, bathe, cook, drive)?‟

– Paraphrasing Technique • The interviewer repeats information presented by the patient. • Advantage: can assist in fostering effective, accurate communication between the patient and the physical therapist. • Example: – „You‟ve told me that the pain is relieved by walking around, is that right? What other activities or treatment brings you relief from your pain or symptoms?‟

• If the therapist cannot paraphrase what the patient has said, or is unclear about the meaning of the patient‟s response, clarification is achieved by requesting an example of what the patient is talking about.

• Interviewing Tools – Are self-assessment forms. – Are employed to identify problems, to quantify symptoms, and to demonstrate the effectiveness of treatment. – There is no single interviewing tool that can be considered to be the best under all circumstances.

– Most common interviewing tool employed, especially for pain, is the McGill Pain Questionnaire.

• Identifying Data/Demographics – Majority of information in Identifying Data/Demographics are written in a medical record or referral before the PT has examined and evaluated the patient thus Identifying Data/Demographics are considered data gathered from the documentation of other healthcare professionals.

– Importance of the Identifying Data/Demographics: • Certain diseases have a specific demographic characteristic • It gives an idea on the kind of approach a PT would make when interviewing and examining a patient • It helps in anticipating social problems • It facilitates conduct of epidemiologic researches, as well as follow-up researches

– Types • Enumerated • Narrative

• Enumerated (Example 1): Name: Marciano, George Age: 28 y.o. Address: 10 Fairlane Village, Brgy. Guadalupe, Cebu City Sex: ♂ Nationality: Filipino Civil Status: Single Occupation: Encoder Religion: Roman Catholic Handedness: ® Physiatrist: Dr. J. Lasco Date of Eval: November 19, 2003 Dx: ® Carpal Tunnel Syndrome Medications: Alaxan PT Imp. : Impaired grip 2˚ to ® Carpal Tunnel Syndrome

• Enumerated (Example 2): Name: Marciano, George Age: 28 y.o. Address: 10 Fairlane Village, Brgy. Guadalupe, Cebu City Sex: ♂ Nationality: Filipino Civil Status: Single Occupation: Encoder

Religion: Roman Catholic Handedness: ® Physiatrist: Dr. J. Lasco Date of Eval: November 19, 2003 Dx: ® Carpal Tunnel Syndrome Medications: Alaxan PT Imp. : Impaired grip 2˚ to ® Carpal Tunnel Syndrome

• Narrative: Case of George Marciano, a 28 y.o. ♂, single, Filipino, Roman Catholic, encoder currently residing in 10 Fairlane Village, Brgy. Guadalupe, Cebu City who was evaluated and referred for PT by Dr. J. Lasco November 19, 2003 with a diagnosis of ® Carpal Tunnel Syndrome.

• Stating the Problem or Diagnosis – Usually is stated in a medical record or referral under the heading Dx.: – In some facilities, pertinent history or medical information taken from the chart is included in the Problem or Diagnosis – Dx.: is included in the Identifying Data/Demographics since it is usually obtained from the documentation of other healthcare professionals.

– Some information to be included in the Problem or Dx.: • • • • •

Past surgeries Past conditions/diseases Present conditions/diseases Test results Recent or past surgery

affecting the present condition / treatment

– Examples: • Dx.: ® hemiplegia resulting from craniotomy for removal of tumor on 11-17-03 • 58 y.o. ♂ c- ® BKA on 11-8-03 2˚ to PVD. Hx of DM.

• Writing Subjective Content – Any information that the patient or significant other tells the therapist directly. – Importance of Assessing Subjective Information: • To plan how to evaluate the Objective portion of the examination to determine what tests and measures to use • To justify or explain certain goals that are set with the patient

– Categorizing Items as Subjective: • Anything the patient or significant other tells the therapist regarding • Activities that the patient can no longer perform due to the patient‟s current condition (prior level of function) • The patient‟s history • Something about the patient‟s lifestyle or home situation • Emotions or attitudes

• • • •

Goals Complaints Response to treatment Anything relevant to the patient‟s case or present condition

– The use of „Patient‟ • Acceptable to use „Pt.‟ the first time, but not to be repeated with every sentence. • Assumed, unless otherwise stated, that the information in Subjective came from the patient.

– Organization: • Organize by topic • Subcategories or headings may be used to facilitate searching for information

– Frequently Used Verbs in the Subjective Content: • Subjective content frequently contain a verb which indicates that the statement is subjective and not taken from the chart. – – – – –

States Describes Denies Indicates C/o (complains of)

– Quoting the Patient Verbatim: • At times, quoting the patient verbatim is the appropriate method of conveying subjective information • Some reasons for using direct quotes from the patient or significant other: – – – –

To illustrate confusion or loss of memory To illustrate denial To illustrate a patient‟s attitude toward therapy To illustrate the patient‟s use of abusive language

– Using Information Taken from a Family Member or Significant Other: • Should state the exact relation of the patient to the informant • Introduced before the actual statement

• Items Usually Included in the Subjective Content: – C/C: (chief complaint) • There can be only ONE chief complaint • Relate to patient‟s function as much as possible

• If pain, state the following: – – – – – – – – – – –

Onset Location Quality/character Progression Intensity Frequency Variability Duration Migration pattern Precipitating, aggravating and relieving factors Effect on ADL, sleep, work, social and recreational activities

– Treatment/medications – Other interventions used and results – Association/relationship of the pain with the other symptoms

• ChLORIDEPP –Character –Location –Origin –Radiation –Intensity

–Duration –Events –Provocative –Palliative

– HPI: (history of present illness) • Sequence of events from onset of problem up to referral for PT • Arranged chronologically • May be in narrative or outline form

• Narrative: Patient was apparently well until three days prior to consultation (PTC) when patient noted ® facial asymmetry with ironing out of wrinkles on the ® side of the face. There was associated inability to close the ® eye completely, frequent lacrimation, drooling of liquid food on the ® side of the mouth and difficulty in chewing food with accumulation on the ® side of the oral cavity. There was no hyperacusis or abnormal ear discharge. Persistence of the problem prompted the patient to consult a physiatrist one day after the onset. Patient was diagnosed to have ® Bell‟s Palsy and Prednisone and Tears Naturale were prescribed. He was then referred for PT.

• Outline: 3 days PTC - noted ® facial asymmetry and ironing out of wrinkles. - (+) associated incomplete eye closure ®, frequent tearing ®, drooling of liquid food ®, difficulty in chewing food on ® side of oral cavity. - (-) hyperacusis; (-) pain; (-) ear discharge. 2 days PTC - consulted physiatrist due to persistence. - diagnosed with ® Bell‟s Palsy. - prescribed Prednisone and Tears Naturale. - good compliance with medications. - advised PT. at present - no significant changes noted.

• Important Reminders About the HPI: – Contains both pertinent findings present and absent in the patient – Always describes the functional status of the patient before and after the onset of the illness – Must be arranged in chronological order – Must describe the clinical course of the illness

– PMH: (past medical history) • Includes other illnesses that: – Are known risk factors of the current disease – May alter the clinical course of the current illness and thus affect prognosis – May affect the management of the patient

• Other items that may be included here: – FDA – Smoking Hx. – Drinking Hx. – Drug Hx.

– HFD: (hereditofamilial diseases) • Presence of illness or state of health in the family (father, mother, brothers, and sisters) and relatives

– FDA: (food and drug allergies) – Home Situation: • Living arrangements • Describes the physical and social aspects of the home • Includes: – Support system – Environmental assessment

– Pt.‟s Lifestyle: • Personal, social, and environmental history • May include: – Smoking Hx: – Drinking Hx: – Drug Hx: – Daily Activities: – Work Activities: – Recreational Activities: – Pre-morbid Status:

– Pt.‟s Goal: • Anticipated goals and expected outcomes for the patient/client

• Special Considerations Regarding Subjective Content in a Pediatric or Obstetric Case – Have additional components

– Pediatric Cases • Includes: – Birth and maternal history » If patient is still a neonate, these are included in the HPI » Information obtained are: 1.Number of days post-delivery if neonate 2.Age of gestation (AOG) at the time of delivery and/or term 3.Nature of delivery 4.APGAR score at the time of birth 5.Place of delivery and who attended to the delivery

6. Presence/absence of maternal illnesses, accidents and other problems during the pre-natal, perinatal and post-natal periods 7. Presence/absence of pre-natal care, with whom and how regularly 8. Intake of any medications, recreational drugs or abortifacients when the mother was pregnant with the baby 9. Attitude of the parents toward the pregnancy

– Nutritional history » Important in pediatric conditions that result from undernutrition or malnutrition – Immunization history » Important in pediatric conditions that may be prevented through immunization – Developmental history » Important in pediatric conditions presenting with developmental delay

– Obstetric Cases • Includes: – Parity – Obstetric scores

Patient Encounter Tips • Patient Interview Tips • Non-verbal Communication

Obtaining and Documenting Objective Content •

Introduction to Objective Data – The objective part of the note is the section in which the results of measurements performed and the therapist‟s objective observations of the patient are recorded. – Objective data are the measurable or observable information used to plan patient treatment. – Testing procedures that produce objective data are repeatable.

• Categorizing Items as Objective Data – An item is considered objective if: • It is part of the patient‟s history taken from the medical record and relevant to the problem. – Not all facilities include information from the medical record – Example: O: Hx: ASHD, CHF, COPD. S/P fx (L) hip c prosthesis insertion 1 yr.

• It is a result of the therapist‟s objective measurements or observations. – Must be measurable and reproducible data – Are written in the objective part of a note but usually are summarized versions of the following: » Databases » Flow sheets » Charts » Specific assessment forms

– If none of the above-mentioned forms are available, only pertinent (important) data are to be written in the objective part – Example: O: AROM: WNL throughout UEs & LEs except 0°-120° (L) shoulder flexion noted.

• It is part of the treatment given to the patient. – Data obtained here are written in other notes aside from the evaluation notes (interim (progress) notes, discharge notes/summaries, turnover notes, and referral notes) – Particularly: » Modifications used » Number of repetitions tolerated » Pain relieved or caused – This provides information to anyone who might treat the patient as to what was done in a treatment session on a certain date

– Also done to inform both those reimbursing the treatment and those who might read the medical record as a legal document of what was specifically done with the patient – Example: O: PT Mx received: 1. PJM to (R) shoulder using Gr. I inferior glides, Gr. II distraction. 2. AROM exercises to (R) shoulder flexion-extension, abduction-adduction & medial rotation-lateral rotation, 10 reps X 3 sets each c 5-secs isometrics @ end-ranges. 3. Ice massage to anterior, posterior, lateral & superior aspects of (R) shoulder X 5 mins.

• It is a patient education activity. – Usually written in other notes aside from the evaluation notes – Many agencies accrediting patient care facilities are very interested in written evidence of what PTs teach patients and families – Example: O: Patient Education: Received instruction in home exercise program & was indep in same program (attached).

• Organization of Objective Data – Using categories or headings make information organized, easy to read, and easy to find.

– Categories of headings can be based on: • Types of tests and measures performed. – Helpful when a patient has deficits on multiple areas or has a generalized problem. – Example: Ambulation Transfers Balance ROM Strength Sensation

– Categories of headings can be based on: • Areas of the body and functional skills. – Helpful when a patient has deficits only on one or two parts of the body. – Example: Ambulation ADL UEs LEs Trunk

– Placing objective data into categories or headings depends on: • The diagnosis and deficits of the individual patient. – The therapist categorizes information in the manner that they deem most efficient and organized. – Used in some facilities only.

• Facility rules and guidelines on documentation. – The therapist categorizes information on ALL patients in the same manner despite differences in diagnoses and deficits between patients. – The usual basis of placing items under a category/heading.

– Methods of using categories or headings: • Functional categories first before nonfunctional categories. – The therapist presents functional categories before the nonfunctional categories. – May also be presented with the functional category first then outlining directly after the functional deficit the nonfunctional deficit(s) that contributed to the functional deficit. – Most preferred method by other readers of the note (e.g. physicians, third-party payers, et al).

– Methods of using categories or headings: • Nonfunctional categories first before functional categories. – The therapist has to present first the nonfunctional categories that lead to a functional deficit.

– Within any individual category/heading, the following rules are followed: • Organize information in the most logical order possible. • Joints are described one at a time, usually in a cephalo-caudal manner and from proximal to distal.

• Common Mistakes in Recording Objective Data – Some of the most common mistakes in recording objective data are: • Failure to state the affected part. • Failure to put items in measurable terms. – If an item cannot be stated in measurable terms, the word „appears‟ instead of „is‟ should be used. – Should be used cautiously as third-party payers do not reimburse for intervention that „appears‟ necessary.

• Failure to state the type of whatever it is that is being measured or observed.

• Some Specifics Regarding Recording Objective Data – When using scales with numerical values, always include the normal value to make the job of other people rearing the note for thirdparty payers easier. • Example: MMT: 3/5 versus fair.

– When using scales with analog values, always include the scale or rating system used and the definition for each value. • Example: Deep Tendon Reflexes: (O=areflexia/absent; +=hyporeflexia; ++=normoreflexia; +++=hyperreflexia. ++++=abnormal with 1 - 3 beats of clonus: +++++=abnormal with sustained clonus).

• Example using a combined numerical/analog scale: Pain: 5/10 using visual analog pain scale (VAPS) (0=no pain: 1=minimum perceivable pain; 5= moderate pain; 10=worst possible pain).

– Abbreviations & Medical Terminology • Minimize use of abbreviations and use only universally accepted abbreviations or the facility's approved abbreviations. • Use only appropriate medical terminology with correct spelling.

Objective Content I: Systems Review • The Systems Review – A briefer limited examination of: • The anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal. and neuromuscular systems and • The communication ability, affect, cognition, language, and learning style of the patient/client – The physical therapist especially notes how these affect the ability to initiate, sustain, and modify purposeful movement for performance of an action, task, or activity that is pertinent to function

– Also assists the physical therapist in identifying possible problems that require consultation with or referral to another provider.

• Components of the Systems Review – The systems review includes the following: • • • • •

Cardiovascular/Pulmonary System Integumentary System Musculoskeletal System Neuromuscular System Communication Ability, Affect, Cognition, Language, and Learning Style

• Cardiovascular/Pulmonary System: – – – –

Heart rate Respiratory rate Blood pressure Edema

• Integumentary System – Skin integrity – Skin color – Presence of scar formation

• Musculoskeletal System – – – – –

Gross symmetry Gross range of motion Gross strength Height Weight

• Neuromuscular System – Gross coordinated movement (e.g.. balance, locomotion, transfers, and transitions)

• Communication Ability, Affect, Cognition, Language, and Learning Style – – – – –

Ability to make needs known Consciousness Orientation (person, place, and time) Expected emotional/behavioral responses Learning preferences (e.g., teaming barriers, education needs)

Objective Content II: Tests and Measures • Introduction to Tests and Measures – The means of gathering data about the patient/client. – Physical therapists individualize the selection of tests and measures based on the history they take and systems review they perform, rather than basing their selection on a previously determined medical diagnosis.

– From the history and systems review, the physical therapist determines patient/client needs and generates diagnostic hypotheses that may be further investigated by selecting specific tests and measures. • These are used to rule out causes of impairment and functional limitations; establish a diagnosis, prognosis, and plan of care; and select interventions.

– The tests and measures that are performed as part of an initial examination should be only those that are necessary to: • Confirm or reject a hypothesis about the factors that contribute to making the current level of patient/client function less than optimal, and • Support the physical therapist‟s judgments about appropriate interventions, anticipated goals, and expected outcomes.

– Before, during, and after administering the tests and measures, physical therapists gauge responses, assess physical status, and obtain a more specific understanding of the condition and the diagnostic and therapeutic requirements.

– The physical therapist may decide to use one, more than one, or portions of several specific tests and measures as part of the examination. • These are based on the purpose of the visit, the complexity of the condition, and the directions taken in the clinical decision-making process.

– As the examination progresses, the physical therapist may identify additional problems that were not uncovered by the history and systems review and may conclude that other specific tests and measures or portions of other specific tests and measures are required to obtain sufficient data to perform an evaluation, establish a diagnosis and a prognosis, and select interventions.

• The examination therefore may be as brief or as lengthy as necessary. – The physical therapist may decide that a full examination is necessary and then select appropriate tests and measures. – Conversely, the physical therapist may conclude from the history and systems review that further examination and intervention are not required, that the patient/client should be referred to another practitioner, or both.

– Tests and measures vary in the precision of their measurements; however, useful data may be generated through various means. • For instance, data generated from either a gross muscle test of a group of muscles or from a very precise manual muscle test could be used to reject the hypothesis that muscle performance is contributing to a functional deficit.

• Similarly, even though a functional assessment instrument may quantify a large number of ADL or IADL, it may fail to detect the inability to perform a particular task and activity that is most important to the patient.

– The tests and measures that are selected by the physical therapist should yield data that are sufficiently accurate and precise to allow the therapist to make a correct inference about the patient‟s/client‟s condition.

• The selection of specific tests and measures and the depth of the examination vary based on: – – – – –

Age of the patient/client Severity of the problem Stage of recovery Phase of rehabilitation Home, community, or work (job/school/play) situation, and – Other relevant factors.

– After the initial examination, tests and measures are used: • To document changes in patient/client status, and • To indicate achievement of the outcomes that are the end-points of care and thereby ensure timely and appropriate discharge.

• What is Measurement? – According to APTA‟s Standards for Tests and Measurements in Physical Therapy Practice: • The numeral assigned to an object, event, or person OR the class (category) to which an object, event, or person is assigned to according to rules.

– Obtaining measurements is an everyday part of physical therapy practice.

– Physical therapists obtain many different types of measurements. Examples of which are: • Assessing the magnitude of a patient‟s report of pain • Quantifying muscle performance or range of motion • Describing the various characteristics of a patient‟s gait pattern • Categorizing the assistance that a patient requires

– The physical therapist collects data through many different methods, such as: • • • • • • •

Interviewing Observation Questionnaires Palpation Auscultation Conducting performance-based assessments Electrophysiological testing

– The physical therapist collects data through many different methods, such as: • Taking photographs and making other videographic recordings • Recording data using scales, indexes, and inventories • Obtaining data through the use of technologyassisted devices • Administering patient/client self-assessment tests • Reviewing patient/client diaries and logs

– Physical therapists use tests and measures to obtain measurements, which they then use to interpret to identify: • Signs and symptoms of pathology/pathophysiology (disease, disorder, or condition such as: – – – – –

Joint tenderness Pain Elevated blood pressure with activity Numbness and tingling Edema

– Physical therapists use tests and measures to obtain measurements, which they then use to interpret to identify: • Impairments such as: – – – – – – – –

Aerobic capacity Anthropometric characteristics Arousal, attention, and cognition Circulation Cranial and peripheral nerve integrity Ergonomics and body mechanics Gait, locomotion, and balance Integumentary integrity

– Physical therapists use tests and measures to obtain measurements, which they then use to interpret to identify: • Impairments such as: – – – – – – – – –

Joint integrity and mobility Motor function Muscle performance Neuromotor development and sensory integration Posture Range of motion Reflex integrity Sensory integrity Ventilation and respiration/gas exchange

– Physical therapists use tests and measures to obtain measurements, which they then use to interpret to identify: • Functional limitations such as: – Work (job/school/play), community, and leisure integration or reintegration (including IADL) – Ergonomics and body mechanics – Self-care and home management (including ADL and IADL)

• Disabilities such as: – Inability to engage in community, leisure, social, and work roles

– Physical therapists use tests and measures to obtain measurements, which they then use to interpret to identify: • Device and equipment need and use such as: – Assistive and adaptive devices – Orthotic, protective, and supportive devices – Prosthetic devices

• Barriers such as: – Environmental, home, and work (job/school/play) barriers

– In the evaluation process, the physical therapist synthesizes the examination data to establish the diagnosis and prognosis (including the plan of care). • The data gathered through the use of tests and measures during initial examination provide information used for determining anticipated goals and expected outcomes.

• These data may: – Indicate initial abilities in performing actions, tasks, and activities – Establish criteria for placement decisions, and – Identify level of safety in performing a particular task or risk of injury with continued performance with or without devices and equipment

– Reexamination at regular intervals during an episode of care enables the physical therapist to measure and document: • Changes in patient/client status, and • The progress that the patient/client is making toward the anticipated goals and expected outcomes

• Reliability and Validity of Measurements – Whenever possible, physical therapists should use measurements whose reliability and validity have been documented in the peer-reviewed literature. – Reliable and valid measurements enable physical therapists to gauge: • The certainty of their examination data, and • The appropriate scope of inferences that may be drawn from those data

– Reliability and validity are properties of a measurement, not the test or measure used to obtain the measurement. – A measurement is reliable only under certain conditions and for certain types of patients/clients and is valid only for a particular purpose.

– Reliability and validity have not yet been reported for every measurement used by physical therapists. • Use of measurements without established reliability and validity may be appropriate, however, especially when there are no alternatives – and provided that the physical therapist is aware that those measurements may be prone to error and that, therefore, decisions made using those measurements may be less certain.

• Reliability of Measurements – Assessing a measurement‟s reliability is an attempt to identify sources of error. A measurement is said to be reliable when it is consistent time after time, with as little variation as possible.

– Because all measurements have some error, however, the clinician must determine whether a measurement is useful or whether there is so much error that the measurement is rendered useless for a particular purpose.

– Two Major Types of Reliability: • These help to determine how much error exists in a particular measurement. 1.Test-retest Reliability 2.Intra-rater/Inter-rater Reliability

1.Test-retest Reliability • The consistency of repeated measurements that are separated in time when there is no change in what is being measured. • Indicates the stability of a measurement.

2. Intra-rater/Inter-rater Reliability a. Intra-rater Reliability • Indicates the degree to which measurements that are obtained by the same physical therapist at different times will be consistent. b. Inter-rater Reliability • Indicates the degree to which measurements obtained by multiple therapists will be consistent. • Especially important – if different physical therapists obtain different measurements when measuring the same phenomenon, the usefulness of the measurements is limited.

– Other Forms of Reliability: 1.Parallel-form Reliability – Relates to measurements that are obtained by using different versions of the same test or measure.

2.Internal Consistency/Homogeneity – Relates to measurements that are obtained by using tests or measures with multiple items or parts, where each part is supposed to measure one, and only one, concept.

• Validity of Measurements – The degree to which a useful (meaningful) interpretation can be inferred from a measurement. – Forms of Validity: 1.Face Validity 2.Content Validity 3.Construct Validity 4.Concurrent Validity 5.Predictive Validity

1.Face Validity – Exists when the measurement seems to reflect what is supposed to be measured – but it does not depend on evidence. – Example: goniometric measurements – have face validity as measurements of joint position.

2.Content Validity – Establishes the degree to which a measurement reflects the domain of interest. – Example: instruments to assess joint pain – might generate data only regarding pain on motion, not pain at rest or factors that aggravate or alleviate pain.

3.Construct Validity – A theoretical form of validity that is established on the basis of evidence that a measurement represents the underlying concept of what is to be measured. » Example: the overall concept of „motor function‟ is the construct that underlies any particular test or measure of motor function.

3.Construct Validity – There are no direct tests of construct validity. » Theoretical evidence of construct validity is often provided by demonstrating convergence if tests or measures believed to represent the same construct are highly related. Example of Convergence: a test of motor function, based on a particular concept of what „motor function‟ means, should correlate highly with other tests or measures based on similar conceptions of „motor function‟ or on concepts that are closely related to „motor function,‟ such as „dexterity and coordination.‟

3.Construct Validity – There are no direct tests of construct validity. » Evidence of construct validity is also found when there is a low association, or divergence, between a test or measure of one particular construct and other tests or measures reflecting distinctly different, or even unrelated, constructs. Example of Divergence: there should be low association between a test of „motor function‟ and tests and measures that are based on the concepts of „aerobic conditioning‟ or „range of motion.‟

4.Concurrent Validity – Exists when an inferred interpretation is justified by comparing a measurement with supporting evidence that was obtained at approximately the same time as the measurement being validated. – Example: developers of a new balance test might compare the measurements obtained using the new test to those obtained using an established balance test involving one-legged stance. – The comparative method of establishing concurrent validity is particularly relevant for self-assessment instruments.

5. Predictive Validity – Exists when an inferred interpretation is justified by comparing a measurement with supporting evidence that is obtained at a later point in time and examines the justification of using a measurement to say something about future events or conditions. – Knowing the predictive validity of a measurement may facilitate the identification of achievable outcomes and increase the efficiency of discharge planning. » Example: predictive validity of a measurement of functional capacity might be established by verifying whether the measurement indicates the likelihood of return to work.

5. Predictive Validity – Predictive validity may also provide the physical therapist of information about the value of selecting particular tests or measures for the examination, such as: » Sensitivity of a Measurement -Indicates the proportion of individuals with a positive finding who already have or will have a particular characteristic or outcome. -The positive predictive validity of a measurement. » Specificity of a Measurement -Indicates the proportion of individuals with a negative finding who truly do not or will not have a particular characteristic or outcome. -The negative predictive validity of a measurement.

• Clinical Utility of a Measurement – A physical therapist must also consider the clinical utility of the test or measure for a particular purpose, specifically: • Precision of the data yielded by a test or measure • Whether it will meet the needs of the situation • The time involved in administering a test or measure • The cost of administering a test or measure, and • Patient/client factors such as tolerance of testing positions and suitability of the test or measure to a particular population

– Some measurements are only gross measurements. • Gross measurements may be useful for a population screen but may not be useful for identifying a small change in patient/client status after intervention.

– The measurements used by the physical therapist should always be sensitive enough to detect the degree of change expected as a result of intervention.

• Categories of Tests and Measures – There are a total of twenty-four (24) categories of tests and measures that physical therapists commonly perform.

– Each categorization of tests and measures includes: • General definition and purpose of the test and measure. • Clinical indications. • Tests and measures. (methods and techniques) • Tools used for gathering data. • Data generated. • Other Information that may be required for the examination.

• General definition and purpose of the test and measure. – A definition and purpose of the test and measure is provided. – All tests and measures produce information used to identify the possible or actual causes of difficulties during performance of essential everyday activities, work tasks, and leisure pursuits.

• General definition and purpose of the test and measure. – Selection of tests and measures depends on the findings of the history and systems review. » The examination may indicate, for instance, that tests should be conducted while the patient/client performs specific activities. – In all cases, the purpose of tests and measures is to ensure the gathering of information that will lead to evaluation, diagnosis, prognosis, and selection of appropriate interventions.

• Clinical indications. – Examples of clinical indications are identified during the history and systems review are provided to indicate the use of tests and measures. – Special requirements may prompt the physical therapist to perform tests and measures.

• Clinical indications. – All tests and measures are appropriate in the presence of: » Impairment, functional limitation, disability, developmental delay, injury, or suspected or identified pathology that prevents or alters performance of daily activities, including self-care, home management, work (job/school/play), community, and leisure actions, tasks, or activities. » Requirements of employment that specify minimum capacity for performance. » Identified risk factors. » Need to initiate programs that promote health, wellness, or fitness.

• Tests and measures. (methods and techniques) – Examples of specific tests and measures are provided.

• Tools used for gathering data. – A listing of tools used for collecting data is provided.

• Data generated. – Types of data that may be generated from the tests and measures are listed.

• Other Information that may be required for the examination. – Includes: » Findings of other professionals » Results of diagnostic imaging, clinical laboratory, and electrophysiological studies » Federal, state, and local work surveillance and safety reports and announcements, and » Reported observations of family members, significant others, caregivers, and other interested people

• Important Tests and Measures in Generalized Conditions – Concentrate examination of the patient on the items listed below each generalized condition.

• Musculoskeletal Conditions – Observation of: » General attitude of patient » General posture » Willingness to move » Gait » Obvious deformities (abnormal curvatures, joint subluxation, asymmetrical body contours, swelling, and color and texture of skin) NOTE: If the above are present, a more detailed examination is necessary.

• Musculoskeletal Conditions – Palpation » Areas of pain and tenderness » Areas of restriction » Swelling » Anatomical orientation of structures

• Musculoskeletal Conditions – – – – – – –

AROM PROM Strength Flexibility (including joint play and muscle length tests) Functional tests (ADL and IADL) Special tests Other diagnostic procedures

• Neuromuscular Conditions – – – – – – –

Arousal, attention, and cognition Communication Functional tests (ADL and IADL) Motor control Tone Sensation and perception Flexibility

• Cardiopulmonary Conditions – Cardiovascular diagnostic tests and procedures – Pulmonary diagnostic tests and procedures

• Integumentary Conditions – Integumentary integrity and condition (including vascular compromise, trauma, disease, and scar tissue)

– In any condition, always check for presence or risk of secondary complications.

– Special Conditions: • Require additional tests and measures. – Pediatric Conditions » Developmental milestones. – Geriatric Conditions » Generally, all categories of tests and measures are included.