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Right-sided radiculopathy centralizing with repeated extension•Left-sided hemiplegia- Brunnstrom Stage III: all movements in synergy with marked spasticity•Evaluation, Dx, Prognosis, all go in assessment, what you do at that point, at that first
visit goes in O, you actually did it. PLANNED interventions go in P including frequency and duration. Assessment should include:•Physical therapy problems•Other problems that may impact the patient’s physical functioning or participation in a plan of care (medical, social, financial)•The relationship between impairment and function•A plausible physical therapy diagnosis•Summary of the patient’s status•The need for skilled services•Prognosis with reasonable, measurable, functional goals•Patient’s potential to benefit from PT interventionsFirst: Problem ListProblem List:We have all this info from the history and the exam so how will we organize it?Problem list should have specific PT! problems to be addressed not medical problems. Problems PT CAN addressYou probably won’t see a problem list in a standard SOAP note when you go into the clinics but for now we will include it bc it will help write goals and determine appropriate interventions. Include:oImpairments of body fxn or structuresoFxnal or activity limitationsoAny disability, or participation restrictions that you find during the examinationprocessoFocus should be on function. Should indicate any clear connection b/w impairments and function, those should be linked.Considering the whole patientBiopsychosocial Models of healthcare:•ICF model (WHO): “whole person”•Patients/clients are viewed as complex human beings with biological (physical) functioning that is always influenced by and exerts an influence on psychosocial functioning.•Back to the question – what is going on there?Problem list defined•Body structure or function limitations or Impairments: any loss or abnormality ofa body part (i.e. structure) or body function (i.e. physiological function). The physiological functions include mental functions.