Assessment Portion of the SOAP Note Flashcards
What types of things does the PT discuss about pt progress in the evaluation portion of the Assessment section?
- Explanation of why pt not meeting goals
- Explanation of why pt exceeding goals
- Explanation of why pt regressed
What 3 relationships does the PT describe in the Assessment?
- connections between examination findings
- how impairments relate to functional deficits
- how functional deficits keep the pt from functioning in his/her environment
4 Importances of the Assessment
- A reflection of the physical therapist’s clinical judgment
- Often includes a summary of the deficits or functional impairments the pt presents with
- Viewed by other health care providers to assess pt deficits
- Viewed by third-party payers to justify treatment
If you beleive a pt needs further testing what do you do?
“Pt may benefit from further medical diagnostic testing due to continued pain and deficits with right shoulder.”
*Doctors do not like when a PT says that a patient needs an MRI
In the evaluation portion of the Assessment section what two things must the PT justify?
- Continuing therapy
- Assistive device selected
What 3 things are included in the Assessment Section?
1) The Evaluation
2) The Diagnosis
3) The Prognosis
What 2 inconsistancies must the PT document in the evaluation portion of the Assessment section?
- Inconsistencies between examination findings
- Inconsistencies between objective and subjective findings
When must you refer a patient to another practitioner?
When examination findings indicate deficit that does not fall within PT scope of practice
Medical Diagnosis vs. PT Diagnosis
Medical diagnosis:
- Describes medical signs and systems and directs medical interventions
PT diagnosis
- Describes the impact that functional deficits or impairments have on the person’s functional ability
2 Purposes of the Diagnosis portion of the Assessment section?
1) Helps identify the PT Guide Practice Pattern
2) Helps identify movement dysfunction categories
What is the Prognosis?
Statement that predicts a level of improvement in function and an amount of time needed to reach that level
What 4 things does the prognosis take into account?
1) the severity of the pt’s functional deficits and impairments
2) pt’s living environment
3) pt’s goals
4) pt’s PLOF
