Final third of semester Flashcards
For initial eval notes what belongs in the Subjective?
things the patient reports
pt hx
personal experiences
For initial eval notes what belongs in the Objective?
tests and measures
treatments
MMT and ROM
systems review
functional measures
For initial eval notes what belongs in the Assesment ?
PT diagnosis
prognosis
goals
my opinoins
for initial eval notes what belongs in PLan?
future treatment
detailed interventions
progressions
Daily progress notes?
S:patients progress, compliance with HEP, updates
O:interventions provided, changes in status, adverse rxns
A:therapists impression of progression, tx impact, challenges
P:upcoming interventions
Rexamination notes
S:updates on pain and function
O:repeat previously tested
A: goal review
P:plan contunation and adjustments
discharge notes
summarize the care
achieved goals
current status
HEP
referals
reason for discharge
follow up reccomondations
medicare
progress reports every 30 days
JUSTIFY need for treatment
order of hx of condition
chief complaint
mechansim of injury
date
location of symotoms
description
pain rating
symptom behaviour
order of history taking
hx of current condition
PMhx
activity limitations
participation restrictions
prior level of fucntion
living enviorment
medications
psychosocial
goals for PT
next md visit
OLBIA
onset
location
behaviour
influence
assosciated factors
nominal measures
checklist of tasks
ordinal measures
scale describes range of perfomance
interval measures
provide infro about order and posses equal intervals between measurements
ex. SAT temp
no absolute zero
ratio measures
have an absolute zero