Evaluation, Diagnosis, Prognosis, Intervention, and Documentation

Question 1

Summarize what examination is

Answer 1

• Comprehensive screening and specific testing process leading to a diagnostic classification or referral to another practitioner
• Observation of function
• Collect history, systems review, and perform tests and measures

Question 2

What is gathered in a history?

Answer 2

• Demographics
• Social history and social health habits
• Employment
• Growth/development
• Living environment
• Current conditions and chief complaints
• Medical and surgical history and medications
• Functional status and activity level

Question 3

What are the four of the most important questions to ask during a history?

Answer 3

• What does a typical day look like for your child? (provides information about ADL’s, routines, other services received, and much more information that the parent may divulge)
• Any past medical or surgical history, any medications? (provides information about any other conditions, may give insight to other tests to be done in examination, lets you know of any precautions)
• What are your biggest concerns or goals for the child? (narrows your focus)
• What motor milestones has the child already achieved? (learn their level of development, compare to typical development)

Question 4

What is examined during the systems review?

Answer 4

• Cardiovascular/pulmonary: HR, RR, BP, edema
• Integumentary: pliability, scar formation, skin color, skin integrity
• Musculoskeletal: gross symmetry, gross ROM, strength, height, weight
• Neuromuscular: coordinated movement (balance, gait, locomotion, transfers, transitions), motor function (motor control and learning)
• Communicative ability, affect, cognition, language, and learning style

Question 5

What is the purpose of tests and measures?

Answer 5

• Rule in and rule out impairments
• Aids in establishing diagnosis, prognosis, plan of care, and interventions

Question 6

Summarize what evaluation is

Answer 6

• The process of making clinical judgements based on data from examination
• Synthesize findings from history, systems review, and tests and measures to establish diagnosis, prognosis, and plan of care
• Development of strengths and needs list

Question 7

What is included in a strengths and needs list?

Answer 7

• Strengths: list out the patient’s abilities and supports that help the patient to achieve the intended outcome, can use to your advantage in treatment
• Needs: areas that require change to effect function, diagnosis is not included

Question 8

What is included in documentation when determining a diagnosis and what is the purpose?

Answer 8

• Brief summary reflecting the patient’s condition, level of function, and potential for improvements
• Labels and identify the impact of a condition on function at the level of the system and holistically
• Referrals to other disciplines or medical professionals

Question 9

What is the purpose of prognosis?

Answer 9

• Determination of the predicted optimal level of improvement in function and how long it will take to reach their goal
• Includes plan of care

Question 10

What is the plan of care?

Answer 10

• Goals and outcomes
• Predicted level of improvement
• Interventions to be performed
• Duration and frequency of treatment
• Discharge plans

Question 11

Outcome goals are included in POC, what must they include?

Answer 11

• Audience, behavior, condition, degree, and function
• Must include time frames

Question 12

What is included in discharge plans?

Answer 12

• Statement o potential needs at the conclusion of an episode of care and/or service delivery
• Monitor and follow up as appropriate