Practical Patient Management Model

Question 1

Examination/Evaluation

Answer 1

History 				® Demographics
					® Social history
					® Employment/work
					® Environment
					® Growth and development
					® General health status
					® Social/health habits
					® Family history
					® c/c/current condition
					® Functional status
					® Medication
					® Clinical tests
Sys. Review
					® What leads you towards tests and measures
					® Gross ROM/Gross strength from general screen prospective
					® Systems to gather data from:
						◊ Cardiovascular/Pulmonary
							} Vitals/edema
						◊ Musculoskeletal
							} Gross range of motion 
							} Gross strength 
							} Gross symmetry and posture
						◊ Integumentary
							} Pliability (texture) 
							} Presence of scar formation 
							} Skin color 
							} Skin integrity 
						◊ Neuromuscular
					® Can also include:
						◊ Affect (screen demeanor/look for lack of responsiveness/distractible/emotional/pain), communication, cognition (caregiver? Understand commands?, learning barriers, educational needs)
						◊ Be careful of word choice since public records
Tests and Measures
					® Things that we're doing as part of big picture of the examination that help with Dx and Px
					® Based upon history and sys. review
Does not have to be an outcome measure (has reliability and

Question 2

Evaluation

Answer 2

□ Functional tasks and impairments
□ Problem list
□ Have functional context to impairments
□ Key factors that influence POC moving forward

Question 3

Dx

Answer 3

§ Leads to billable codes

§ PT diagnosis can expand diagnosis to include how it affects movement sys./participation

Question 4

Prognosis

Answer 4

§ Predict course of outcome for medical condition
§ Think about how many visits
§ Think about what the nature of the condition means down the road

Question 5

Plan of Care

Answer 5

§ Overall, measurable goal
§ Interventions (specificity)
§ Discharge plan
§ Proposed duration and frequency

Question 6

Progress note

Answer 6

be specific

Question 7

Re-Examination

Answer 7

§ Documentation of components of initial examination to update impairments, function, or disability status
§ See if POC needs to be adjusted
§ See if personal/environmental factors have changed

Question 8

Discharge Summary

Answer 8

§ Stop point where certain goals were met; what's the next step
			§ Think about discharge disposition
			§ Additional services
			§ Recommendations for follow up
			§ Caregiver training