MSK2 DOCUMENTATION

Question 1

PT Diagnosis

Answer 1

<participation> as manifested by <activity> dt <impairments>.

inability to attend classes as manifested by difficulty in prolonged ambulation and stair negotiation due to joint effusion, pain, LOM and muscle atrophy
</impairments></activity></participation>

Question 2

Prognosis

Answer 2

The Pt is <rehab> as to <desired> p <time> as supported by the following prognosticating factors:</time></desired></rehab>

table here

The Pt has good prognosis as to independent sitting on chair c back support for 3 hr s pain p 3 weeks as supported by the following prognosticating factors:

Question 3

Rehabilitative LTG

Answer 3

ABCDE

Pt will reach objects within extended arm’s length distance (>0.75 m) by extending his R elbow s trunk flex & s diff p 7 wks of PT session.

Question 4

Preventive LTG

Answer 4

ABC(*)DE

Pt will identify ~3 hazards for injury associated c his sport p 3 wks of PT sessions.

Question 5

STG

Answer 5

ABC(*)DEF

Pt will demonstrate increased ROM in (R) elbow extension from 30 deg flex –> 0 deg extension p 4 wks of PT sessions to improve reaching objects within arm’s length

Question 6

Treatment Planning

Answer 6

The Pt will be seen and treated as (I.P. or O.P.) every (schedule) for (how many sessions or length of physical therapy) c the following interventions:

Pt will be seen & treated as O.P. q MWF for 2 wks c following PT Mx:

Question 7

MWM

Answer 7

MWM on (R) elbow using lat glide towards flex in supine x 8 reps x 3 sets to address painful arc