Documenting Objective Information

Question 1

Systems Review

Answer 1

• 6 systems to be included
• cardiopulmonary
• integumentary
• musculoskeletal
• neuromuscular
• communication/cognition

Question 2

Tests and Measures

Answer 2

• results of physical examination of patient
• baseline data that helps to develop prognosis and plan of care
• impairment based tests-based on screening; test specific aspects that may be an issue
• function: generic (overall aspects) and specific (diagnosis or body type) measures
• measuring function: patient performance vs. self report

Question 3

Describing Interventions

Answer 3

• communication with other healthcare providers and with patient
• instructions/informed consent
• skilled language: proof that PT is necessary and can’t get same outcome without it

Question 4

Other

Answer 4

• specific to needs of patient
• initial, interim, discharge summary differences-“Today’s Treatment:”
• subheadings and tables to organize