Right-sided radiculopathy centralizing with repeated extension
•
Left-sided hemiplegia- Brunnstrom Stage III: all movements in synergy with marked
spasticity
•
E
valuation, 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 interventions
First: Problem List
Problem 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 address
You 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:
o
Impairments of body fxn or structures
o
Fxnal or activity limitations
o
Any disability, or participation restrictions that you find during the examination
process
o
Focus should be on function
.
Should indicate any clear connection b/w
impairments and function, those should be linked.
Considering the whole patient
Biopsychosocial 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 of
a body part (i.e. structure) or body function (i.e. physiological function). The
physiological functions include mental functions.
