Documenting the Examination (Patient/Client Note)

Question 1

Why do we gather subjective information first?

Answer 1

To identify the patient problem

Question 2

Why do we perform objective tests and measures?

Answer 2

To help support or disprove the information gathered during the subjective interview

Question 3

What subjective information should be included in the initial evaluation, progress notes, and discharges?

Answer 3

The overall patient description

For example: Pt is a 65 yr-old female, R hand-dominant, seen in outpatient facility c her daughter present for R shld pn from torn RC c impaired fxnal ability

OR

Pt is 45 yr-old male seen for 10 visits for s/p L ACL repair on 3/17/12

Question 4

In a Patient/Client Note what are the 3 subsections of the examination?

Answer 4

1) History
2) Systems Review
3) Tests and Measures

Question 5

What 12 things are included in the History section of a Pt/Client Note?

*These are also referred to as the headings

Answer 5

1) Demographic information
2) Chief complaints
3) Patient goals
4) Prior level of function
5) Cultural / religious beliefs
6) Employment status
7) Living environment
8) General health status / Family health history
9) Hobbies
10) Surgical history / Medical tests performed
11) Current functional status
12) Medications

Question 6

When is the only time you must refer to the source of information in the history subsection?

Answer 6

When information from two sources conflicts despite the therapist’s attempts to clarify discrepancies.

Question 7

What 9 things are included in the Systems Review section of a Pt/Client Note?

Answer 7

(1) Cardiovascular / Pulmonary
(2) Integumentary
(3) Musculoskeletal
(4) Neuromuscular
(5) Communication
(6) Affect (emotions)
(7) Cognition
(8) Learning style
(9) Education needs

Question 8

Information gathered in the Systems Review will be reported how?

Answer 8

Either impaired or not impaired

** Cardiovascular / Pulmonary information is rated the same way, however individual measurements are recorded as well

Question 9

4 Types of Information gathered in the Cardiovascular / Pulmonary section of the Systems Review

Answer 9

(1) Heart Rate
(2) Blood Pressure
(3) Respiratory Rate
(4) Edema

Question 10

4 Types of Information gathered in the Integumentary System section of the Systems Review

Answer 10

(1) Integumentary disruption
(2) Continuity of Skin Color
(3) Skin Pliability
(4) Skin Texture

Question 11

5 Types of Information gathered in the Musculoskeletal System section of the Systems Review

Answer 11

(1) Gross symmetry during standing, sitting, and activities
(2) Gross ROM
(3) Gross Muscle Strength
(4) Height
(5) Weight

Question 12

4 Types of Information gathered in the Neuromuscular System section of the Systems Review

Answer 12

(1) Gait
(2) Locomotion (transfers, bed mobility)
(3) Balance
(4) Motor Control

Question 13

What type of information does the Communication section of the Systems Review include?

Answer 13

Includes whether the patient’s communication is age-appropriate

Question 14

What type of information does the Affect section of the Systems Review include?

Answer 14

The patient’s emotional and behavioral responses

Question 15

What type of information does the Learning Abilities section of the Systems Review include?

Answer 15

(1) Vision or hearing problems
(2) Inability to read
(3) Inability to understand what is read
(4) Language Barriers

Question 16

What type of information does the Cognition section of the Systems Review include?

Answer 16

Involves whether the patient is oriented to person, place, time, and situation

Question 17

What type of information does the Education Needs section of the Systems Review include?

Answer 17

Reports areas in which the patient needs more education or information such as disease process, safety, use of devices, or equipment, ADLs, Exercise Program, Recovery and Healing Process, etc.

Question 18

What 8 things are included in the Tests and Measures section of a Pt/Client Note?

Answer 18

(1) Ambulation
(2) Transfers
(3) Balance
(4) ROM
(5) Strength
(6) Sensation
(7) ADLs
(8) Special Tests

Question 19

Which Section of the Pt/Client Note needs to be the most organized and why?

Answer 19

The Test and Measures Section

- because it is often the only read section of the evaluation

Question 20

4 Common Mistakes in recording data from tests and measures

Answer 20

• Failure to state the affected body part
• Failure to state measurable information
• Failure to state the “type” of whatever is that is being measured (AROM vs. PROM rather than just listing ROM)
• Failure to record values from the unaffected side