PART I:

INTRODUCTION TO THE CLINICAL

SETTING
I. Physical Therapists and hat They D!
(APTAs Guide to Physical Therapist Practice)
A. Ed"cati!n and #"ali$icati!ns
%. Physical Therapist
Is required to have the following:
a. Pr!$essi!nally ed"cated at the c!lle&e !r "ni'ersity le'el in physical
therapy c"rric"la appr!'ed (y the appr!priate accreditati!n (!dy
(. Licensed in the state !r states in )hich they practice
*. Clinical Specialist
Is a physical therapist that has advanced clinical practice competency with a
certificate awarded by the specialty-regulating body of the professional association in any of the
following specialty areas:
a. Cardi!'asc"lar and P"l+!nary Physical Therapy
(. Clinical Electr!physi!l!&y
c. Geriatric Physical Therapy
d. Ne"r!l!&ic Physical Therapy
e. Orth!pedic Physical Therapy
$. Pediatric Physical Therapy
&. Sp!rts Physical Therapy
,. Practice Settin&s
Physical therapists practice in a broad range of inpatient, outpatient, and
community-based settings, including the following:
%. H!spitals -critical care. intensi'e care. ac"te care. and s"(/ac"te care0
*. O"tpatient clinics !r !$$ices
1. Reha(ilitati!n $acilities
2. S3illed n"rsin&. e4tended care. !r s"(/ac"te $acilities
5. H!+es
6. Ed"cati!n !r research centers
7. Sch!!ls and play&r!"nds -presch!!l. pri+ary. and sec!ndary0
8. H!spices
9. C!rp!rate !r ind"strial health centers
%:. Ind"strial. )!r3place. !r !ther !cc"pati!nal en'ir!n+ents
%%. Athletic $acilities -c!lle&iate. a+ate"r. and pr!$essi!nal0
%*. ;itness centers and sp!rts trainin& $acilities
C. Patients and Clients
%. Patients
Individuals who are the recipients of physical therapy examination, evaluation,
diagnosis, prognosis, and intervention and who have a disease, disorder, condition, impairment,
functional limitation, or disability
*. Clients
Individuals or organizations (eg businesses, school systems, athletic teams! who
engage the services of a physical therapist and who can benefit from the physical therapist"s
consultation, interventions, professional advice, prevention services, or services promoting
health, wellness and fitness
#enerally accepted elements of patient$client management typically apply to both
patients and clients
D. Sc!pe !$ Practice
Physical %herapy
%he care and services provided by or under the direction and supervision of a
physical therapist
Physical %herapists (P%s!
%he only professionals who provide physical therapy
%. Pr!'ide ser'ices t! patients<clients )h! ha'e i+pair+ents. $"ncti!nal
li+itati!ns. disa(ilities !r chan&es in physical $"ncti!n and health stat"s
res"ltin& $r!+ in="ry. disease. !r !ther ca"ses
&ccording to the 'isablement (odel:
a. I+pair+ent
> )oss or abnormality of anatomical, physiological, mental, or psychological
function
(. ;"ncti!nal Li+itati!n
> *estriction of the ability to perform, at the level of the whole person, a physical
action, tas+ or activity in an efficient, typically expected, or competent manner
c. Disa(ility
> Inability to perform or a limitation in the performance of actions, tas+s, and
activities usually expected in specific social roles that are customary for the
individual or expected for the person"s status or role in a specific socio-cultural
context and physical environment
*. Interact and practice in c!lla(!rati!n )ith a 'ariety !$ pr!$essi!nals
,ollaboration may be with any of the following:
a. Physicians
(. Dentists
c. N"rses
d. Ed"cat!rs
e. S!cial )!r3ers
$. Occ"pati!nal therapists
&. Speech/lan&"a&e path!l!&ists
h. A"di!l!&ists
i. Any !ther pers!nnel in'!l'ed )ith the patient<client
Physical therapists ac+nowledge the need to educate and inform about the cost-
efficient and clinically effective services that physical therapists provide to the following:
a. Other pr!$essi!nals
(. G!'ern+ent a&encies
c. Third/party payers
d. Other health care c!ns"+ers
1. Address ris3
Physical therapists identify ris+ factors and behaviors that may impede optimal
functioning
2. Pr!'ide pre'enti!n and pr!+!te health. )ellness. and $itness
Physical therapists provide prevention services that forestall or prevent functional
decline and the need for more intense care
through timely and appropriate screening, examination, evaluation, diagnosis,
prognosis, and intervention, physical therapists frequently reduce or eliminate the need for
costlier forms of care and also may shorten or even eliminate institutional stays
Physical therapists also are involved in promoting health, wellness, and fitness
initiatives, including education and service provision that stimulate the public to engage in
healthy behaviors
5. C!ns"lt. ed"cate. en&a&e in critical in>"iry. and ad+inistrate
Physical therapists provide consultative services to health facilities, colleagues,
businesses, and community organizations and agencies
%hey provide education to patients$clients, students, facility staff, communities, and
organizations and agencies
Physical therapists also engage in research activities, particularly those related to
substantiating the outcomes of service provision
%hey provide administrative services in many different types of practice, research,
and educational settings
6. Direct and s"per'ise the physical therapy ser'ice. incl"din& s"pp!rt pers!nnel
Physical therapists oversee all aspects of the physical therapy service
%hey supervise the physical therapist assistant (P%&! when the P%&s provide
physical therapy interventions as selected by the physical therapist
Physical therapists also supervise any support personnel as they perform designated
tas+s related to the operation of the physical therapy service
E. R!les in Pri+ary Care
Physical therapists have a ma-or role to play in the provision of primary care,
which has been defined as:
.%he provision of integrated, accessible health care services by clinicians who are
accountable for addressing a large ma-ority of personal health care needs, developing a
sustained partnership with patients, and practicing within the context of family and community"
&P%& has endorsed the concepts of primary care set forth by the Institute of
(edicine"s ,ommittee on the /uture of Primary ,are, including the following:
Primary care can encompass myriad needs that go well beyond the capabilities and
competencies of individual caregivers and that require the involvement and interaction of varied
practitioners
Primary care is not limited to the .first contact" or point of entry into the health care
system
%he primary care program is a comprehensive one
%. Ac"te +"sc"l!s3eletal and ne"r!+"sc"lar c!nditi!ns
%riage and initial examination are appropriate physical therapist responsibilities
%he primary care team may function more efficiently when it includes physical
therapists, who can recognize musculos+eletal and neuromuscular disorders, perform
examinations and evaluations, establish a diagnosis and prognosis, and intervene without delay
Physical therapy intervention may result not only in more efficient and effective
patient care but also in more appropriate utilization of other members of the primary care team
0ith physical therapists functioning in a primary care role and delivering early
intervention for wor+-related musculos+eletal in-uries, time and productivity loss due to in-uries
may be dramatically reduced
1xample of primary care intervention which physical therapists may engage in a
patient$client with low bac+ pain:
a. I++ediate pain red"cti!n thr!"&h pr!&ra+s $!r pain +!di$icati!n.
stren&thenin&. $le4i(ility. and p!st"ral ali&n+ent
(. Instr"cti!n in ADL
c. !r3 +!di$icati!n
*. Certain chr!nic c!nditi!ns
Physical therapists should be recognized as the principal providers of care within the
collaborative primary care team
Physical therapists are well prepared to coordinate care related to loss of physical
function as a result of musculos+eletal, neuromuscular, cardiovascular$pulmonary, or
integumentary disorders
2sually through community-based agencies and school systems
1. Ind"strial and )!r3place settin&s
Physical therapists manage the occupational health services provided to employees
and help prevent in-ury by designing or redesigning the wor+ environment focusing on both the
individual and the environment to ensure comprehensive and appropriate intervention
;. R!les in Sec!ndary and Tertiary Care
%. Sec!ndary care settin&s
Patients with musculos+eletal, neuromuscular, cardiovascular$pulmonary, or
integumentary disorders may be treated initially by another practitioner and then referred to
physical therapists for secondary care in a wide range of settings, including acute care and
rehabilitation hospitals, outpatient clinics, home health, and school systems
*. Tertiary care settin&s
Physical therapists provide tertiary care in highly specialized, complex, and
technology-based settings (eg heart and lung transplant units, burn units! or in response to
other health care practitioners" requests for consultation and specialized services (eg for
patients with spinal cord lesions or closed-head trauma!
G. R!les in Pre'enti!n and in the Pr!+!ti!n !$ Health. ellness. and ;itness
Physical therapists are involved in:
Prevention
Promoting health, wellness, and fitness
Performing screening activities
%hese initiatives decrease costs by helping patients$clients:
&chieve and restore optimal functional capacity
(inimize impairments, functional limitations, and disabilities related to congenital and
acquired conditions
(aintain health (thereby preventing further deterioration or future illness! and
,reate appropriate environmental adaptations to enhance independent function
%. Pre'enti!n
%hree types of prevention in which physical therapists are involved:
a. Pri+ary pre'enti!n
> Preventing a target condition in a susceptible or potentially susceptible
population through such specific measures as general health promotion efforts
(. Sec!ndary Pre'enti!n
> 'ecreasing duration of illness, severity of disease, and number of sequelae
through early diagnosis and prompt prevention
c. Tertiary Pre'enti!n
> )imiting the degree of disability and promoting rehabilitation and restoration of
function in patients with chronic and irreversible diseases
*. Pre'enti!n screenin&
Physical therapists conduct screenings to determine the need for:
a. Pri+ary. sec!ndary. !r tertiary pre'enti!n ser'ices
(. ;!r $"rther e4a+inati!n. inter'enti!n. !r c!ns"ltati!n (y a physical
therapist !r
c. Re$erral t! an!ther practiti!ner
,andidates for screening generally are not patients$clients currently receiving
physical therapy services
3creening is based on a problem-focused, systematic collection and analysis of data
1xamples of prevention screening activities in which physical therapists may engage:
a. Identi$icati!n !$ li$estyle $act!rs -e.&. a+!"nt !$ e4ercise. stress. )ei&ht0
that +ay lead t! increased ris3 $!r seri!"s health pr!(le+s
(. Identi$icati!n !$ children )h! +ay need an e4a+inati!n $!r idi!pathic
sc!li!sis
c. Identi$icati!n !$ elderly indi'id"als in a c!++"nity centre !r n"rsin& h!+e
)h! are at hi&h ris3 $!r $alls
d. Identi$icati!n !$ ris3 $act!rs $!r ne"r!+"sc"l!s3eletal in="ries in the
)!r3place
e. Pre/per$!r+ance testin& !$ indi'id"als )h! are acti'e in sp!rts
1. Pre'enti!n acti'ities and health. )ellness. and $itness pr!+!ti!n acti'ities
1xamples of prevention activities and health, wellness, and fitness promotion
activities in which physical therapists may engage:
a. ,ac3 sch!!ls. )!r3place redesi&n. stren&thenin&. stretchin&. and
end"rance e4ercise pr!&ra+s? p!st"ral trainin& t! pre'ent and +ana&e l!)
(ac3 pain
(. Er&!n!+ic redesi&n? stren&thenin&. stretchin&. and end"rance e4ercise
pr!&ra+s? p!st"ral trainin& t! pre'ent =!(/related disa(ilities. incl"din&
tra"+a and repetiti'e stress in="ries
c. E4ercise pr!&ra+s. incl"din& )ei&ht (earin& and )ei&ht trainin&. t!
increase (!ne +ass and (!ne density -especially in !lder ad"lts )ith
!ste!p!r!sis0
d. E4ercise pr!&ra+s. &ait trainin&. and (alance and c!!rdinati!n acti'ities t!
red"ce the ris3 !$ $alls @ and the ris3 !$ $ract"res $r!+ $alls @ in !lder ad"lts
e. e4ercise pr!&ra+s and instr"cti!n in ADL -sel$/care. c!++"nicati!n. and
+!(ility s3ills re>"ired $!r independence in daily li'in&0 and IADL -acti'ities
that are i+p!rtant c!+p!nents !$ +aintainin& independent li'in&. s"ch as
sh!ppin& and c!!3in&0 t! decrease "tiliAati!n !$ health care ser'ices and
enhance $"ncti!n in patients )ith cardi!'asc"lar<p"l+!nary dis!rders
$. E4ercise pr!&ra+s. cardi!'asc"lar c!nditi!nin&. p!st"ral trainin&. and
instr"cti!n in ADL and IADL t! pre'ent disa(ility and dys$"ncti!n in )!+en
)h! are pre&nant
&. ,r!ad/(ased c!ns"+er ed"cati!n and ad'!cacy pr!&ra+s t! pre'ent
pr!(le+s -e.&. pre'ent head in="ry (y pr!+!tin& the "se !$ hel+ets?
pre'ent p"l+!nary disease (y enc!"ra&in& s+!3in& cessati!n0
h. E4ercise pr!&ra+s t! pre'ent !r red"ce the de'el!p+ent !$ se>"elae in
indi'id"als )ith li$e/l!n& c!nditi!ns
H. Other Pr!$essi!nal R!les !$ the Physical Therapist
%. C!ns"ltati!n
%he rendering of professional or expert opinion or advice by a physical therapist
%he consulting physical therapist applies highly specialized +nowledge and s+ills to
identify problems, recommended solutions, or produce a specified outcome or product in a
given amount of time in behalf of a patient$client
Patient-related consultation
> 3ervice provided by a physical therapist at the request of a patient, another
practitioner, or an organization to recommend physical therapy services that are
needed or to evaluate the quality of physical therapy services being provided
> 2sually does not involve actual intervention
,lient-related consultation
> 3ervice provided by a physical therapist at the request of an individual, business,
school, government agency, or other organization
1xamples of consultation activities in which physical therapists may engage:
a. Ad'isin& a re$errin& practiti!ner a(!"t the indicati!ns $!r inter'enti!n
(. Ad'isin& e+pl!yers a(!"t the re>"ire+ents !$ the Ba&na Carta $!r
Disa(led Pers!ns
c. C!nd"ctin& a pr!&ra+ t! deter+ine the s"ita(ility !$ e+pl!yees $!r
speci$ic =!( assi&n+ents
d. De'el!pin& pr!&ra+s that e'al"ate the e$$ecti'eness !$ an inter'enti!n
plan in red"cin& )!r3/related in="ries
e. Ed"catin& !ther health care practiti!ners -e.&. in in="ry pre'enti!n0
$. E4a+inin& sch!!l en'ir!n+ents and rec!++endin& chan&es t! i+pr!'e
accessi(ility $!r st"dents )ith disa(ilities
&. Instr"ctin& e+pl!yers a(!"t =!( pre/place+ent in acc!rdance )ith
pr!'isi!ns !$ the Ba&na Carta $!r Disa(led Pers!ns
h. Participatin& at the l!cal. re&i!nal. and nati!nal le'els in p!licy+a3in& $!r
physical therapy ser'ices
i. Per$!r+in& en'ir!n+ental assess+ents t! +ini+iAe the ris3 $!r $alls
=. Pr!'idin& peer re'ie) and "tiliAati!n re'ie) ser'ices
3. Resp!ndin& t! a re>"est $!r a sec!nd !pini!n
l. Ser'in& as an e4pert )itness in le&al pr!ceedin&s
+. !r3in& )ith e+pl!yees. la(!r "ni!ns. and &!'ern+ent a&encies t!
de'el!p in="ry red"cti!n and sa$ety pr!&ra+s
*. Ed"cati!n
%he process of imparting information or s+ills and instructing by precept, example,
and experience so that individuals acquire +nowledge, master s+ills, or develop competence
In addition to instructing patients$clients as an element of intervention, physical
therapists may engage in education activities such as:
a. Plannin& and c!nd"ctin& acade+ic ed"cati!n. clinical ed"cati!n. and
c!ntin"in& ed"cati!n pr!&ra+s $!r physical therapists. !ther pr!'iders.
and st"dents
(. Plannin& and c!nd"ctin& pr!&ra+s $!r l!cal. re&i!nal. and nati!nal
a&encies
c. Plannin& and c!nd"ctin& pr!&ra+s $!r the p"(lic t! increase a)areness !$
iss"es in )hich physical therapists ha'e e4pertise
1. Critical In>"iry
%he process of applying the principles of scientific methods to read and interpret
professional literature4 participate in, plan, and conduct research4 evaluate outcomes data4 and
assess new concepts and technologies
1xamples of critical inquiry activities in which physical therapists may engage:
a. AnalyAin& and applyin& research $indin&s t! physical therapy practice and
ed"cati!n
(. Disse+inatin& the res"lts !$ research
c. E'al"atin& the e$$icacy and e$$ecti'eness !$ (!th ne) and esta(lished
inter'enti!ns and techn!l!&ies
d. Participatin& in. plannin&. and c!nd"ctin& clinical. (asic. !r applied
research
2. Ad+inistrati!n
%he s+illed process of planning, directing, organizing, and managing human,
technical, environmental, and financial resources effectively and efficiently
Includes the management, by individual physical therapists, of resources for
patient$client management and for organizational operations
1xamples of administration activities in which physical therapists may engage:
a. Ens"rin& $iscally s!"nd rei+("rse+ent $!r ser'ices rendered
(. ,"d&etin& $!r physical therapy ser'ices
c. Bana&in& sta$$ res!"rces. incl"din& the ac>"isiti!n and de'el!p+ent !$
clinical e4pertise and leadership a(ilities
d. B!nit!rin& >"ality !$ care and clinical pr!d"cti'ity
e. Ne&!tiatin& and +ana&in& c!ntracts
$. S"per'isin& assisti'e pers!nnel and !ther assisti'e pers!nnel
I. The Physical Therapy Ser'ice: Directi!n and S"per'isi!n !$ Pers!nnel
'irection and supervision are essential to the provision of high-quality physical
therapy
%he degree of direction and supervision necessary for ensuring high-quality
physical therapy depends on many factors, including:
1ducation, experience, and responsibilities of the parties involved
5rganizational structure in which the physical therapy is provided
&pplicable state law
In any case, supervision should be readily available to the individual being
supervised
%. Direct!r !$ the Physical Therapist Ser'ice
& physical therapist who has demonstrated qualifications based on clinical education
and experience in the field of physical therapy and who has accepted the inherent
responsibilities of the role
*esponsibilities of the director of the physical therapy service:
a. Esta(lish &"idelines and pr!ced"res that )ill delineate the $"ncti!ns and
resp!nsi(ilities !$ all le'els !$ physical therapy pers!nnel in the ser'ice
and the s"per'is!ry relati!nships inherent t! the $"ncti!ns !$ the ser'ice
and the !r&aniAati!n
(. Ens"re that the !(=ecti'es !$ the ser'ice are e$$iciently and e$$ecti'ely
achie'ed )ithin the $ra+e)!r3 !$ the stated p"rp!se !$ the !r&aniAati!n
and in acc!rdance )ith sa$e physical therapist practice
c. Interpret ad+inistrati'e p!licies
d. Act as liais!n (et)een line sta$$ and ad+inistrati!n
e. ;!ster the pr!$essi!nal &r!)th !$ the sta$$
> 0ritten practice and performance criteria should be available for all levels of
physical therapy personnel in a physical therapy service
> *egularly scheduled performance appraisals for all levels of physical therapy
personnel in a physical therapy service should be conducted by the director of
the physical therapy service based on applicable standards of practice and
performance criteria
> *esponsibilities should be commensurate with the qualifications 6 including
experience, education, and training 6 of the individuals to whom the
responsibilities are assigned
&lso has responsibilities borne solely by physical therapists (shown below!
*. Physical Therapist
0hen the physical therapist directs assistive personnel to perform specific
components of physical therapy interventions, that physical therapist remains responsible for
supervision of the plan of care
*egardless of the setting in which the service is given, the following responsibilities
must be borne solely by a physical therapist:
a. Interpretati!n !$ re$errals )hen a'aila(le
(. Initial e4a+inati!n. e'al"ati!n. dia&n!sis. and pr!&n!sis
c. De'el!p+ent !r +!di$icati!n !$ a plan !$ care that is (ased !n the initial
e4a+inati!n !r the re/e4a+inati!n and that incl"des physical therapy
anticipated &!als and e4pected !"tc!+es
d. Deter+inati!n !$:
> 0hen the expertise and decision-ma+ing capability of the physical therapist
requires the physical therapist to personally render physical therapy interventions
and
> 0hen it may be appropriate to utilize the physical therapist assistant
- 7a physical therapist determines the most appropriate utilization of the physical therapist assistant
that will ensure the delivery of service that is safe, effective, and efficient
e. Pr!'isi!n !$ physical therapy inter'enti!ns
$. Re/e4a+inati!n !$ the patient<client in li&ht !$ the anticipated &!als and
e4pected !"tc!+es. and re'isi!n !$ the plan !$ care )hen indicated
&. Esta(lish+ent !$ the dischar&e plan and d!c"+entati!n !$ dischar&e
s"++ary<stat"s
h. O'ersi&ht !$ all d!c"+entati!n $!r ser'ices rendered t! each patient
1. Assisti'e Pers!nnel
Person(s! who may assist the physical therapist either in selected components of
intervention or some other aspect of the overall care of a patient
a. Physical Therapist Assistants -PTAs0
> %he only certified paraprofessionals who assist in the provision of physical
therapy interventions under the direction and supervision of the physical therapist
(. Physical Therapy Aides -PT Aides0
> Persons trained under the direction of a physical therapist who perform
designated and supervised routine tas+s related to physical therapy
> 8either licensed nor certified
> #enerally trained on the -ob
2. Other Assisti'e Pers!nnel
Persons licensed or certified in another discipline (eg massage therapists, exercise
physiologists, athletic trainers! but who are employees in a physical therapy service under the
supervision of a physical therapist
,onsidered and represented as P% &ides if used within the physical therapy service
If such persons are providing consultative services, then they are not represented or
billed under physical therapy service but under their specific service disciplines
5. S"pp!rt Pers!nnel
8ot involved directly in patient care
(anagement, clerical or maintenance wor+ers
II. Pre$erred Practice Patterns in Physical Therapy
(APTAs Guide to Physical Therapist Practice)
A. Intr!d"cti!n
&P%&"s #uide to Physical %herapist Practice
&lso +nown as the #uide
&P%& developed the #uide as a resource not only for physical therapist clinicians,
educators, researchers, and students, but for health care policy ma+ers, administrators,
managed care providers, third-party payers, and other professionals
%he #uide serves the following purposes:
a. T! descri(e physical therapist practice in &eneral. "sin& the Disa(le+ent
B!del as the (asis
(. T! descri(e the r!les !$ physical therapists in pri+ary. sec!ndary. and
tertiary care? in pre'enti!n? and in the pr!+!ti!n !$ health. )ellness. and
$itness
c. T! descri(e the settin&s in )hich physical therapists practice
d. T! standardiAe ter+in!l!&y "sed in and related t! physical therapist
practice
e. T! delineate the tests and +eas"res and the inter'enti!ns that are "sed in
physical therapist practice
$. T! delineate pre$erred practice patterns that )ill help physical therapists:
i. I+pr!'e >"ality !$ care
ii. Enhance the p!siti'e !"tc!+es !$ physical therapy ser'ices
iii. Enhance patient<client satis$acti!n
i'. Pr!+!te appr!priate "tiliAati!n !$ health care ser'ices
'. Increase e$$iciency and red"ce "n)arranted 'ariati!n in the pr!'isi!n !$
ser'ices. and
'i. Di+inish the ec!n!+ic ("rden !$ disa(le+ent thr!"&h pre'enti!n and the
pr!+!ti!n !$ health. )ellness. and $itness initiati'es
%he #uide does not provide specific protocols for treatments, nor are the practice
patterns contained in the #uide intended to serve as clinical guidelines
%he preferred practice patterns in the #uide identify the breadth of physical therapist
practice
%hese are the boundaries within which the physical therapist may select and
implement any of a number of clinical alternatives based on consideration of a wide variety of
factors, including:
a. Indi'id"al patient<client needs
(. The pr!$essi!nCs c!de !$ ethics and standards !$ practice
c. Patient<client a&e. c"lt"re. &ender. r!les. race. se4. se4"al !rientati!n. and
s!ci!ec!n!+ic stat"s
%he #uide is not intended to set forth the standard care for which a physical therapist
may be legally responsible in any specific case
,. Pre$erred Practice Patterns in Physical Therapy
/ound in &P%&"s #uide to Physical %herapist Practice (all editions and revisions!
%. ;i'e Ele+ents !$ Patient<Client Bana&e+ent
%he physical therapist integrates the five elements of patient$client management in a
manner designed to optimize outcomes
%he first four elements are all part of a process that helps the physical therapist
determine the most appropriate intervention(s! (fifth element! to address the outcomes that are
desired by the patient$client
a. E4a+inati!n
> *equired prior to the initial intervention and is performed for all patients$clients
> Initial examination is a comprehensive screening and specific testing process
leading to diagnostic classification or, as appropriate, to a referral to another
practitioner
> ,omponents:
i. Hist!ry
- 3ystematic gathering of data 6 from both the past and the present 6 related to why the
patient$client is see+ing the services of the physical therapist
ii. Syste+s Re'ie)
- & brief or limited examination of:
ii.a The anat!+ical and physi!l!&ical stat"s !$ the cardi!'asc"lar<p"l+!nary.
inte&"+entary. +"sc"l!s3eletal. and ne"r!+"sc"lar syste+s and
ii.( The c!++"nicati!n a(ility. a$$ect. c!&niti!n. lan&"a&e. and learnin& style
!$ the patient<client
o %he physical therapist especially notes how these affect the ability to initiate,
sustain, and modify purposeful movement for performance of an action, tas+, or
activity that is pertinent to function
- &lso assists the physical therapist in identifying possible problems that require consultation with
or referral to another provider
iii. Tests and Beas"res
- %he means of gathering data about the patient$client
- /rom the history and systems review, the physical therapist determines patient$client needs and
generates diagnostic hypotheses that may be further investigated by selecting specific tests and
measures
- %hese are used to:
iii.aR"le !"t ca"ses !$ i+pair+ent and $"ncti!nal li+itati!ns
iii.(Esta(lish a dia&n!sis. pr!&n!sis. and plan !$ care
iii.cSelect inter'enti!ns
(. E'al"ati!n
> &re clinical -udgments of the physical therapist that are based on the data
gathered from the examination that are synthesized to establish the diagnosis,
prognosis, and plan of care
c. Dia&n!sis
> 'iagnostic labels
- (ay be used to describe multiple dimensions of the patient$client, ranging from the most basic
cellular level to the highest level of functioning 6 as a person in society
i. Typical physician dia&n!stic la(els
- Identification of a disease, disorder, or condition at the level of the cell, tissue, organ, or system
ii. Physical therapist dia&n!stic la(els
- Identification of the impact of a condition on function at the level of the system (especially the
movement system! and at the level of the whole person
d. Pr!&n!sis -incl"din& the Plan !$ Care0
i. Pr!&n!sis
- %he determination of the predicted optimal level of improvement in function and the amount of
time needed to reach that level
- (ay also include a prediction of levels of improvement that may be reached at various intervals
during the course of therapy
ii. Plan !$ Care
- ,onsists of statements that specify the anticipated goals and expected outcomes, predicted level
of optimal improvement, specific interventions to be used, and proposed duration and frequency of the
interventions that are required to reach the anticipated goals and expected outcomes
- %herefore describes:
ii.a Speci$ic patient<client +ana&e+ent
ii.( Ti+in& $!r patient<client +ana&e+ent $!r the epis!de !$ physical therapy
care
e. Inter'enti!n
> %he purposeful interaction of the physical therapist and the patient$client and,
when appropriate, with other individuals involved in patient$client care, using
various physical therapy procedures and techniques to produce changes in the
condition that are consistent with the diagnosis and prognosis
> ,omponents:
i. C!!rdinati!n. C!++"nicati!n. and D!c"+entati!n
- &dministrative and supportive processes intended to ensure that patients$clients receive
appropriate, comprehensive, efficient, and effective quality of care from admission through discharge
i.a C!!rdinati!n
o %he wor+ing together of all parties involved with the patient$client
i.( C!++"nicati!n
o %he exchange of information
i.c D!c"+entati!n
o &ny entry into the patient$client record that identifies the care or service provided
ii. Patient<Client/related Instr"cti!n
- %he process of informing, educating, or training patients$clients, families, significant others, and
caregivers intended to promote and optimize physical therapy services
iii. Pr!ced"ral Inter'enti!ns
- %he physical therapy procedures and techniques
*. Re/e4a+inati!n
%he process of performing selected tests and measures after the initial examination
to evaluate progress and to modify or redirect interventions
(ay be indicated more than once during a single episode of care
(ay also be performed over the course of a disease, disorder, or condition, which for
some patients$clients may be over the life span
Indications for re-examination:
a. Ne) clinical $indin&s
(. ;ail"re t! resp!nd t! physical therapy inter'enti!ns
1. Gl!(al O"tc!+es
%hroughout the entire episode of care, the physical therapist determines the
anticipated goals and expected outcomes for each intervention
9eginning with the history, the physical therapist identifies:
a. Patient<client e4pectati!ns
(. Percei'ed need $!r physical therapy ser'ices
c. Pers!nal &!als and
d. Desired !"tc!+es
%he physical therapist then considers whether these goals and outcomes are
realistic in the context of the examination data and the evaluation
In establishing a diagnosis and a prognosis and selecting interventions, the physical
therapist as+s the question,
> .0hat outcome is li+ely, given the diagnosis:"
%he physical therapist may use re-examination to determine whether predicted
outcomes are reasonable and then modify them as necessary
&s the patient$client reaches the termination of physical therapy services and the end
of the episode of care, the physical therapist measures the global outcomes of the physical
therapy services by characterizing or quantifying the impact of the physical therapy interventions
on the following domains:
a. Path!l!&y<path!physi!l!&y -disease. dis!rder. c!nditi!n0
(. I+pair+ents
c. ;"ncti!nal li+itati!ns
d. Disa(ilities
e. Ris3 red"cti!n<pre'enti!n
$. Health. )ellness. and $itness
&. S!cietal res!"rces
h. Patient<client satis$acti!n
%he physical therapist engages in outcomes data collection and analysis 6 that is,
the systematic review of outcomes of care in relation to selected variables (eg age, sex,
diagnosis, interventions performed! 6 and develops statistical reports for internal or external use
2. Epis!de !$ Care. Baintenance. !r Pre'enti!n
a. Epis!de !$ Physical Therapy Care
> ,onsists of all physical therapy services that are:
i. Pr!'ided (y a physical therapist
ii. Pr!'ided in an "n(r!3en se>"ence and
iii. Related t! the physical therapy inter'enti!ns $!r a &i'en c!nditi!n !r pr!(le+
related t! a re>"est $r!+ the patient<client. $a+ily. !r !ther pr!'ider
> & defined number or identified range of number of visits will be established for an
episode of care
- & visit consists of all physical therapy services provided in a ;<-hour period
> (ay include transfer between sites within or across settings or reclassification of
the patient$client from one preferred practice pattern to another
- *eclassification may alter the expected range of number of visits and therefore may shorten or
lengthen the episode of care
- If reclassification involves a condition, problem, or request that is not related to the initial episode
of care, a new episode of care may be initiated
> & single episode of care should not be confused with multiple episodes of care
that may be required by certain individuals who are classified in particular
patterns
- /or these patients$clients, periodic follow-up is needed over a lifetime to ensure optimal function
and safety following changes in physical status, caregivers, the environment, or tas+ demands
(. Epis!de !$ Physical Therapy Baintenance
> & series of occasional clinical, educational, and administrative services related to
maintenance of current function
> 8o defined number or identified range of number of visits is be established for
this type of episode
c. Epis!de !$ Physical Therapy Pre'enti!n
> & series of occasional clinical, educational, and administrative services related to
prevention, to the promotion of health, wellness, and fitness, and to the
preservation of optimal function
> 8o defined number or identified range of number of visits is be established for
this type of episode
5. Criteria $!r Ter+inati!n !$ Physical Therapy Ser'ices
a. Dischar&e
> %he process of ending physical therapy services that have been provided during
a single episode of care, when the anticipated goals have been achieved
> 'oes not occur with a transfer that is when the patient is moved from one site to
another site within the same setting or across settings during a single episode of
care
> %here may be facility-specific or payer-specific requirements for documentation
regarding the conclusion of physical therapy services as the patient moves
between sites or across settings during the episode of care
> 5ccurs based on the physical therapist"s analysis of the achievement of
anticipated goals and expected outcomes
> /or patients$clients who require multiple episodes of care, periodic follow-up is
needed over the life span to ensure safety and effective adaptation following
changes in physical status, caregivers, environment, or tas+ demands
> In consultation with appropriate individuals, and in consideration of the
anticipated goals and expected outcomes, the physical therapist plans for
discharge and provides for appropriate follow-up or referral
(. Disc!ntin"ati!n
> %he process of ending physical therapy services that have been provided during
a single episode of care, when:
i. The patient<client. care&i'er. !r le&al &"ardian declines t! c!ntin"e inter'enti!n
ii. The patient<client is "na(le t! c!ntin"e t! pr!&ress t!)ard anticipated &!als
and e4pected !"tc!+es (eca"se !$ +edical !r psych!s!cial c!+plicati!ns !r
(eca"se $inancial<ins"rance res!"rces ha'e (een e4pended
iii. The physical therapist deter+ines that the patient<client can n! l!n&er (ene$it
$r!+ physical therapy ser'ices
> 0hen termination of physical therapy services occur prior to achievement of
anticipated goals and expected outcomes, patient$client status and the rationale
for discontinuation are documented
> In consultation with appropriate individuals, and in consideration of the
anticipated goals and expected outcomes, the physical therapist plans for
discontinuation and provides for appropriate follow-up or referral
III. E'idence/,ased Practice and Physical Therapy
(Ramona Hicks, PhD, PT and Jeff oppersmith, !", PT)
(http#$$%%%&herts&ac&uk$lis$su'(ects$health$e'm&htm)
A. hat is E'idence/,ased PracticeD
'avid 3ac+ett originally proposed it for medicine in the early =>>?s 3ince then,
over =,??? articles on this topic have been published in medical -ournals
It is defined as:
@%he -udicious use of the best available evidence together with clinical expertise to
evaluate, select and implement therapy for individual patientsA (3ac+ett et al =>>B!
Primarily, 19P was developed to clarify doubt on clinical diagnosis, prognosis or
management
Important points on the =>>B definition are:
%. E"dici!"s
Implies being careful and well-considered
*. ,est a'aila(le e'idence
1mbodies the most rigorous clinically relevant research across the spectrum of
science from @bench to bedsideA
1. Clinical e4pertise
Includes the clinician"s s+ills and past experience in identifying the patient"s health
state, ma+ing diagnoses and the individual ris+s and benefits of possible interventions
2. Indi'id"al patients -patient pre$erences0
%his ta+es into account each patient"s unique values, preferences and expectations
%hus, it is not solely driven by research studies, but also values clinical expertise
and the wishes of the patient and family when determining optimal interventions
/urthermore, this definition ac+nowledges that not all research evidence is equal,
and that some research studies should be given greater consideration than
others when evaluating therapeutic regimens
%he philosophy of 19( is also relevant to other health care fields, including
physical therapy, and in order to be more inclusive, is now often referred to as
evidence-based practice (19P!
19P has generally, although not universally, been endorsed by health care
professionals for two ma-or reasons /irst, there has been an explosion in
information, with a ten-fold increase in professional -ournals between =><? and
=>>C (President"s I% &dvisory ,ommittee Interim *eport, =>>D! &t this time,
there are more than ;C,??? biomedical -ournals 3econd, rapid advances have
occurred in information technology over the last decade In =>>E, over =??
million people were using the Internet worldwide, a number that is expected to
increase to more than = billion by ;??F (President"s I% &dvisory ,ommittee
Interim *eport, =>>D! 3ince increasing numbers of biomedical -ournals can be
accessed via the Internet, this has greatly increased the accessibility to research
evidence for both clinicians and clients Gowever, the amount and availability of
information can also be daunting %herefore, guidelines on ways to evaluate the
evidence have generally been welcomed 5ther reasons for endorsing 19P are
the concern that the traditional approach of relying on continuing education
courses for +eeping clinical +nowledge and practice up-to-date does not lead to
improvements in clinical performance ('avis, et al, =>>>!, and the need for
greater accountability for reimbursement and liability
2sing interventions that wor+ is what evidence-based practice (19P! is all about
,. H!) D! I ;acilitate The Use O$ E'idence/,ased PracticeD
19P is facilitated through a /ive-3tep Process
%. C!n'ert the need $!r in$!r+ati!n int! a clinically rele'ant. ans)era(le
>"esti!n.
0hat exactly is it that you want to +now: 5ne method for formulating the question is
referred to as PI,5 P refers to the patient or population of interest, I to the intervention, , to
the comparison intervention (if one exists!, and 5 to the outcome
&n example of how to use the PI,5 method to refine a question regarding the role of
exercise for certain clinical problems is shown below
> P 0hat individual or patient populations do I have in mind:
- People with post-polio syndrome
> I 0hat type of exercises am I considering:
- 3trength training
> , Gow does my intervention compare to the effects of another intervention:
0hat is that other intervention:
- *elaxation exercises
> 5 0hat are the goals of the exercise intervention:
- Increased daily activity level
Putting this all together results in a more refined question H/or clients with post-polio
syndrome, is strength training better than relaxation exercises for increasing levels of daily
physical activity:H
*. E$$iciently $ind the (est e'idence.
%his step is often easier said than done, but all things considered, the Internet has
greatly increased the ease with which many clinicians can access and rapidly sort current
information 5f the numerous databases available for information, a few are particularly relevant
to physical therapy
1. Critically appraise the e'idence.
3urprisingly, there are only three critical questions that you need to as+ to appraise
most clinical studies, which are:
a. Is the st"dy 'alidD
(. Are the $indin&s clinically i+p!rtantD
c. D! the $indin&s apply t! +y clientD
Gowever, answering each of these three questions requires a systematic analysis
Indeed, a series of factors needs to be considered when appraising the validity, such as:
a. as the st"dy retr!specti'e !r pr!specti'eD
(. as it rand!+iAedD
c. Did it "se h"+an !r ani+al s"(=ectsD
'epending upon the answers to these and other questions, the validity of the
evidence, or in other words, how close it is to the truth, is ran+ed %o appraise the clinical
importance of the evidence one needs to consider the magnitude of the effect of the
intervention, as well as the probability of the effect generalizing to whole patient populations %o
appraise the applicability of the findings, you must compare your client to the sub-ects used in
the study, consider the feasibility and ris+s and benefits of the intervention, and also determine if
it is in line with the client"s preferences
(astery of step C is available on the web at http:$$cebm-r;oxacu+ and
http:$$wwwfhsmcmasterca$rehab$ebp$
2. Applyin& critically appraised e'idence t! clinical practice.
5f all the steps, this is the one that may be the most difficult
8umerous challenges face health care providers interested in changing their clinical
practice based on 19P %hese challenges include, but are not limited to:
a. A lac3 !$ c!ntr!l !'er their )!r3l!ad
(. C!+petin& pri!rities
c. Li+ited access t! the Internet and<!r =!"rnals
d. Lac3 !$ trainin& in in$!r+ati!n techn!l!&y and critical appraisal !$
literat"re
e. A lac3 !$ instit"ti!nal s"pp!rt $!r E,P
%o overcome these obstacles, it helps to start small /orm a lunchtime -ournal club to
critically appraise relevant clinical studies 9e a Hclinician-scientistH by using valid and reliable
tests and measures to acquire baseline measurements and evaluate outcomes of your clients
3earch for a topic of interest on Pub(ed or another database 9e part of the &P%& Goo+ed on
1vidence Initiative %hese are -ust a few of many possible ways to begin to integrate 19P into
clinical practice
5. E'al"ate the e$$ects !$ E,P !n clinical !"tc!+es.
0hether incorporating 19P into physical therapy practice will increase the li+elihood
that all patients$clients receive interventions that are effective is un+nown %he essence of 19P
is an argument for critical appraisal of therapeutic interventions 0isely, the people who
developed 19P extended this requirement not only to clinical interventions, but also to 19P
itself /uture studies are needed to determine if there is a correlation between the integration of
19P into clinical practice and improvements in outcomes
In conclusion, 19P is a five-step process that aims to improve health care
outcomes by balancing findings from research with clinical experience and
patient$family preferences
C. E'idence/,ased Practice Res!"rces
%. e(sites
a. APTACs H!!3ed !n E'idence Initiati'e
> https:$$wwwaptaorg$hoo+edonevidence$indexcfm
> %he contents of this site provide learning tools to foster evidence based practice
in physical therapy
(. Centre $!r E'idence/,ased Bedicine at O4$!rd Uni'ersity. L!nd!n. En&land
> http:$$cebmr;oxacu+$
> & lot of the original wor+ and dissemination of information about 19P can from
this group of physicians and scientists It is an excellent site and contains current
references on the theory and methodology of 19P, as well as a substantial
annotated list of Internet sites It also contains tutorials and practical guidelines
for incorporating 19P into clinical practice
c. Occ"pati!nal Therapy E'idence/,ased Practice Research Gr!"p
> http:$$wwwfhsmcmasterca$rehab$ebp$
> %his site has great lin+s to guidelines and forms for critical analysis of research
d. Nettin& the E'idence: Lin3s t! e'idence/(ased practice s!"rces
> http:$$wwwshefacu+$Ischarr$ir$corehtml
> %his site has a comprehensive list of annotated evidence-based research
Internet sites
e. E'idence ,ased Health Care / Latest Articles
> http:$$wwwebmnyorg$pubshtml
> %his site may offer some advantages over the ,entre for 1vidence-9ased
(edicine at 5xford 2niversity for members of P%0& because it is located in the
23&
$. The Dart+!"th Atlas !$ Health
> http:$$wwwdartmouthatlasorg$defaultphp
> %his is an interesting site and reinforces the need for systematic analysis of the
ris+s and benefits of various medical and health care interventions
*. e( data(ases
a. Uni'ersity !$ ashin&t!n Li(rary Gate)ay
> http:$$wwwlibwashingtonedu$
> ,lic+ on /ind It to get to databases
(. P"(BED: BEDLINE !$ the Nati!nal Li(rary !$ Bedicine: $ree t! the p"(lic
> http:$$wwwncbinlmnihgov$Pub(ed
> %he largest database of publications on medicine and health care /ree and
available to the public Includes a tutorial (which is highly recommended! on how
to use it to optimize your searches
c. CINAHL Citati!ns in N"rsin& and Allied Health Literat"re
> http:$$wwwcinahlcom$indexhtml
> %his database often includes publications not on Pub(ed, but with high
relevance to physical therapy *equires a site license, which can be for an
individual or group
d. C!chrane Li(rary
> http:$$wwwcochranelibrarycom$clibhome$clibhtm
> %he ,ochrane )ibrary is an electronic publication that contains systematic
overviews of the effects of health care Provides free access to abstracts %he
,ochrane )ibrary is an invaluable source of review articles on important topics,
however often they are more closely lin+ed to medicine, rather than to physical
therapy In the future, the &P%& Goo+ed on 1vidence Initiative may provide a
similar source of information, but with a focus on topics directed toward physical
therapy
e. PEDr!: The Physi!therapy E'idence Data(ase !$ the Centre $!r E'idence/
,ased Physi!therapy. Sch!!l !$ Physi!therapy. Uni'ersity !$ Sydney
A"stralia.
> http:$$ptwwwcchsusydeduau$,19P$indexhtm
> http:$$ptwwwcchsusydeduau$pedro$
> 'esigned for physical therapists, access to bibliographic data, abstracts, and
systematic reviews of the literature Includes a tutorial
$. Reha(Trials.!r&
> http:$$wwwrehabtrialsorg
&. ClinicalTrials.&!'
> http:$$clinicaltrialsgov$
1. Print S!"rces
a. Garrard. E. Health Sciences literat"re re'ie) +ade easy: The +atri4
+eth!d. Gaithers("r&. BD: Aspen? %999.
(. Harris SR. H!) sh!"ld treat+ents (e criti>"ed $!r scienti$ic +eritD
Physical Therapy 76:%75/%8%? %996.
c. La). B. E'idence/(ased reha(ilitati!n: A &"ide t! practice. Th!r!$are. EN:
Slac3? *::*.
d. Sac3ett. DL. Stra"ss SE Richards!n S. R!sen(er& . Hayes R,.
E'idence/(ased +edicine: h!) t! practice and teach E,B. *nd Ed. Ne)
F!r3: Ch"rchill Li'in&st!ne? *:::.
e. T!nelli. B. The phil!s!phical li+its !$ e'idence/(ased +edicine. Acade+ic
Bedicine. 71: %*12/%*2:? %998.
$. Als! see E'idence/,ased Bedicine $!r a list !$ c"rrent and "p/dated
re$erences !n the the!ry and +eth!d!l!&y !$ E,P.
PART II:
PHFSICAL THERAPF
DOCUBENTATION
IG. Intr!d"cti!n t! Physical Therapy D!c"+entati!n
A. P"rp!ses !$ D!c"+entati!n
&ll healthcare professionals document their findings for several reasons:
%. N!tes rec!rd )hat the therapist d!es t! +ana&e the indi'id"al patientCs case.
&ll medical records are legal documents
*. D!c"+entati!n is a +eth!d !$ c!++"nicatin& )ith the patientCs physician and
!ther healthcare pr!$essi!nals. incl"din& !ther therapists and therapist
assistants.
,ommunication through documentation provides consistency between the services
provided by various healthcare professionals
1. Third/party payers +a3e decisi!ns a(!"t rei+("rse+ent (ased !n therapy
n!tes.
*eimbursement decisions can be greatly influenced by the quality and completeness
of documentation
2. ithin the $acility. patient charts are re'ie)ed.
'ischarge or further intervention decisions are made based, in part, on the
documentation written by healthcare professionals
5. Pr!per d!c"+entati!n helps the therapist t! !r&aniAe the th!"&ht pr!cesses
in'!l'ed in patient care.
'ocumentation structures thin+ing for problem solving
6. D!c"+entati!n can (e "sed $!r >"ality ass"rance and i+pr!'e+ent p"rp!ses.
,ertain criteria are set to indicate whether quality care is occurring
7. D!c"+entati!n can (e "sed $!r research.
'ata from documentation can be gathered and conclusions can be drawn
'ocumentation is an integral part of the patient care process as the assessment
or treatment of the patient
,. Relati!nship !$ D!c"+entati!n t! the Decisi!n/+a3in& Pr!cess
'uring an initial session with a patient, the process of assessment and decision-
ma+ing occurs in the following manner:
%. The therapist reads the patientCs chart -+edical rec!rd0 !r re$erral -i$ either is
a'aila(le0.
'ata gathered here are under Identifying 'ata$'emographics
*. The therapist then inter'ie)s the patient.
'ata gathered here are under 3ub-ective
1. ;r!+ the in$!r+ati!n &athered $r!+ the +edical rec!rd and the patient. the
therapist plans the !(=ecti'e +eas"re+ents t! (e per$!r+ed. Then the planned
+eas"re+ents are c!+pleted.
'ata gathered here are under 5b-ective
2. The therapist interprets the in$!r+ati!n rec!rded and identi$ies $act!rs that are
n!t )ithin n!r+al li+its $!r pe!ple in the sa+e a&e ran&e as the patient. ;r!+
these $act!rs. the therapist $!r+"lates a list !$ the patientCs pr!(le+s.
incl"din& $"ncti!nal li+itati!ns. i+pair+ents. and disa(ilities.
'ata here are placed under &ssessment, specifically Problem )ist
5. The therapist and the patient t!&ether esta(lish !"tc!+es that c!rresp!nd t!
the patientCs $"ncti!nal li+itati!ns. i+pair+ents. !r disa(ilities.
'ata here are placed under &ssessment, specifically )ong %erm #oals$/unctional
5utcomes$1xpected 5utcomes
6. The therapist and the patient then c!nsider )hat can (e achie'ed )ithin a
sh!rt peri!d !$ ti+e -anticipated &!als0.
'ata here are placed under &ssessment, specifically 3hort %erm #oals$&nticipated
#oals
7. The therapist $!r+"lates i+pressi!ns !$ the patientCs pr!(le+s and c!nditi!ns.
'ata here are placed under &ssessment, specifically
3ummary$Impression$Prognosis
8. The therapist !"tlines a treat+ent plan t! achie'e the+.
'ata here are placed under Plan$Plan of ,are$Interventions
C. ritin& in a Bedical Rec!rd
%he writing style used in medical records differs from the style most students are
accustomed to using when writing papers, reports, et al
%. Characteristics !$ G!!d D!c"+entati!n in a Bedical Rec!rd:
a. ORGANIHED
> &ll entries in a chart must be arranged in such a way that facilitates use by other
health personnel in the same facility
> In an organized chart:
i. All entries are in their pr!per l!cati!n.
ii. The sheets are pr!perly arran&ed.
iii. The data is rec!rded as a se>"ence !$ e'ents.
> 1ach facility has its own policies on charting and recording, so familiarize
yourself with the policies in every new facility
(. CHRONOLOGICALLF ARRANGED
> &ll entries must have a date and time
> Gas legal implications
> &voids unnecessary duplication of services and unnecessary queries
c. AUTOGRAPHED
> &ll entries must have the printed name and signature of the person who
evaluated$treated the patient at the end of the written report$prescription
d. ;E A,,REGIATIONS
> 2se only internationally accepted abbreviations and use them as infrequently as
possible
> Implications if not followed:
(ay lead to misinterpretation and confusion
5ther users of the chart may not be familiar with the abbreviations used
e. TRUE RECORD O; ACTUAL O,SERGATIONS<IN;ORBATION
> &ll entries must be those that were actually obtained$elicited
> 1ntries must not be copied from other health professionals" documentation but
may be recorded only if therapist repeats the test and confirms the given finding
$. PROBPTLF RECORDED
> &ll entries must be recorded immediately after obtaining them or after treatment
> If not recorded promptly, other health professionals may have written notes
ahead of your note so chart does not become chronologically arranged
&. ,RIE; ,UT COBPLETE. RELEGANT. AND SENSI,LE
> %ime is valuable but this does not be used as an excuse to shortcut procedures,
not to write legibly, use plenty of abbreviations, and$or edit the more important
data
h. LEGI,LE
> 3elf-explanatory
*. ,asic G"idelines in Chartin&<Rec!rdin&
a. Baintain an !r&aniAed and pr!perly arran&ed rec!rd.
(. Pr!+ptly rec!rd all $indin&s.
c. P"t the date and ti+e !$ e'al"ati!n and<!r treat+ent and +aintain a
chr!n!l!&ically arran&ed rec!rd.
d. Bini+iAe "se !$ a((re'iati!ns and "se !nly "ni'ersally accepted
a((re'iati!ns.
e. Rec!rd !nly in$!r+ati!n that )as act"ally !(ser'ed and<!r elicited.
$. Al)ays ac3n!)led&e an entry (y printin& y!"r na+e and a$$i4in& y!"r
si&nat"re a(!'e the printed na+e.
&. D! n!t lea'e spaces (et)een entries t! a'!id ta+perin&.
h. Ne'er chan&e an entry +ade (y an!ther health pr!$essi!n n!r ta+per )ith
any !$ the data c!ntained in a chart.
i. rite le&i(ly.
=. ,e speci$ic and direct t! the p!int.
1. S!+e Speci$ics Re&ardin& ritin& in a Bedical Rec!rd:
Punctuation
a. Hyphen -/0
> ,an be confused with .minus sign" or .negative"
> 1xception only if used instead of the word .through"
> 1xample: ? - <F
(. Se+ic!l!n -?0
> 2sed instead of overusing .states" in the 3ub-ective portion to connect related
statements
> 1xample:
- Instead of: 3tates position of comfort for sleep is on J side 3tates pain does not awa+en pt at
night
- 91%%1*: 3tates position of comfort for sleep is on J side4 pain does not awa+en pt at night
c. C!l!n -:0
> ,an be used instead of .is"
> 1xample:
- Instead of: &*5( J shoulder is ?->?
- 91%%1*: &*5( J shoulder: ?->?
,orrecting 1rrors
> 8ever use correction fluidKKK
> ,harting errors should be corrected by drawing a single line through the error,
write .(error!" above the mista+e, date it, and initial it
> 1xample:
(error! L(P ==$=E$?C
some minM= assist
3igning Nour 8otes
> &ll notes should be signed with your legal signature (your last name and legal
first name or initials!
> 8o nic+names should be used
> Initials should follow your name indicating your status$designation
> 1xample:
J Phoenix
Lason Phoenix, 3P%
*eferring to Nourself
> 8otes discuss the patient and not the therapist
> If a therapist must ma+e reference to himself$herself, reference should be made
in the third person
> 1xample: Pt states therapist should be putting his shoes on for him li+e his
family does at home
3paces, 9lan+s or 1mpty )ines
> 3hould not be left between one entry and another, nor be left within a single entry
> ,ould become areas in which another person could falsify information already
charted
0riting 5rders in a ,hart
> 0hen a physician gives an order to a therapist, the therapist is responsible for
writing it in the chart
> 3tandard format:
date$time$order
vo physician"s name$therapist"s signature, status$designation
5*
date$time$order
verbal order by physician"s name$therapist"s signature, status$designation
> 1xample:
==-=E-?C$==:<F$Pt may ambulate with 9il axillary crutches
JLim lll
vo 'r )im$Luanito )im III, P%*P
2sing &bbreviations and (edical %erminologies
i. A((re'iati!ns:
- (inimize use of abbreviations and use only universally accepted abbreviations
- /amiliarize yourself with a facility"s approved abbreviations
ii. Bedical Ter+in!l!&y:
- (ost medical terms have )atin-based prefixes, suffixes, or roots
- *efer to a medical encyclopedia$dictionary when in doubt
D. Hist!ry !$ De'el!p+ent !$ D!c"+entati!n
%. The SOAP N!te ;!r+at
Introduced by 'r )awrence 0eed as a part of a system organizing the medical
record called the problem-oriented medical record (P5(*!
Gas a patient data base and a list of patient problems in the front of the chart, and
each healthcare practitioner writes a separate 35&P note to address each of the patient"s
problems (ie one (=! 35&P note for each problem!
'isadvantage of P5(* is that it is very tedious and would be very difficult to apply in
centers where healthcare professionals see more than ten (=?! patients a day
(any facilities never use the P5(*
0idespread use of the 35&P note format is one clear contribution
1ach professional field and each facility has its own variation of the 35&P note
format
35&P stands for:
> 3 6 3ub-ective
> 5 6 5b-ective
> & 6 &ssessment
> P 6 Plan
*. ;"ncti!nal O"tc!+es Rec!rdin&
&dapted from the traditional 35&P note format
1mphasizes and discusses the patient"s functional status and sets goals and
treatment to improve function only
G. Trends in Physical Therapy D!c"+entati!n
A. Bedicare ;!r+s
In the 2nited 3tates, (edicare has developed several forms (E??, E?=, E?;! in
an attempt to gather consistent data needed to ma+e decisions about whether
the patient"s condition and treatment qualifies for (edicare coverage
9efore these forms were developed, reviewers for (edicare were receiving poor
quality patient notes
'ata seen in (edicare forms are:
%. De+!&raphic data
*. ,asic +edical data
1. Data that sh!"ld already (e c!ntained in a )ell/)ritten SOAP n!te li3e:
a. ;"ncti!nal stat"s pri!r t! treat+ent
(. C"rrent $"ncti!nal stat"s
c. L!n& ter+ &!als
d. Sh!rt ter+ &!als -listed as +!nthly &!als0
e. Treat+ent plan
$. E"sti$icati!n $!r treat+ent
,. D!c"+entati!n ;!r+s
%his type of documentation is used in many clinics 3ome reasons for this are:
'ecreasing the amount of writing by the therapist$assistant
Increasing the efficiency of the therapist$assistant in documenting patient care
Increasing the consistency of documentation (and thus fulfilling certain quality
assurance or legal$ris+ management requirements! by building certain components into a note,
such as whether the patient is given a home program and his$her level of independence in
performing the home program
(a+ing the data gathered for outcomes studies more consistent
(a+ing functional information easier to read by all parties who use the information
/orms are usually individualized to fit the needs of the individual healthcare
institution and its patient population
%. Types !$ D!c"+entati!n ;!r+s
a. ;l!) sheets
(. Initial assess+ent < dischar&e n!te $!r+s
c. Interi+ < dischar&e n!te $!r+s
d. One/'isit/!nly d!c"+entati!n $!r+s
e. S"pple+ental $!r+s
> %hese forms are to be attached to initial, interim, or discharge forms and often
have specialized tests or scales that are only needed with certain types of
patients
*. De'el!p+ent !$ D!c"+entati!n ;!r+s
0hen designing a form, a good place to start is by watching clinicians practice
wherein items to be included in the form are those that are commonly assessed by the therapist
5ther additions to the forms can be obtained by as+ing staff members to use the forms and give
feedbac+ to those designing the forms
0hen beginning to use a new form, it is important for the therapist $ assistant to give
himself $ herself time to adapt to the use of the form to improve efficiency in the use of the form
%he most efficient use of a form is to complete a form, or at least begin its
completion, while seeing the patient 3ub-ective and ob-ective findings may be written directly on
the form, if permissible, to save time
If a form is limited, specifically if an item is missing from the form, the therapist $
assistant must find a place to write the missing item if it is relevant to the patient"s function
/orms should also be revised on a regular basis to meet the needs of good clinical
practice
0hen developing a form, the following should be considered:
a. D! n!t start $r!+ scratch. Re'ise a $!r+ $r!+ an!ther $acility. )ith
per+issi!n. "sin& the !ther $acilityCs $!r+ as the (asis $!r the present
$acilityCs $!r+.
(. A$ter a dra$t 'ersi!n has (een +ade. th!se )h! "se and read the $!r+s
+"st (e as3ed )hat it is s"pp!sed t! d! $!r all parties in'!l'ed.
c. C!++"nicate )ith all parties in'!l'ed )hen de'el!pin& $!r+s. I$ the $!r+
is t! (e "se$"l. e'ery!ne +"st 3n!) h!) t! "se the $!r+. (!th )ritin& !n
the $!r+ and readin& the $!r+.
d. S"(=ecti'e and !(=ecti'e ite+s c!++!nly assessed (y the sta$$ +"st (e
incl"ded.
e. I$ a standard scale. test. !r de$initi!n !$ +eas"re+ent is "sed (y all sta$$ t!
+eas"re !r d!c"+ent a certain characteristic !$ the patient !r a certain
$acet !$ patient care. a chec3list +ay (e $aster in d!c"+entin& patient care.
$. Chec3lists can sa'e therapist ti+e and add speed in d!c"+entati!n.
&. I$ any s!rt !$ chec3lists are "sed in n!te $!r+s. try t! +a3e the chec3lists
c!nsistent !r si+ilar $r!+ !ne $!r+ t! an!ther t! sa'e c!n$"si!n and
"nnecessary sta$$ re!rientati!n ti+e.
h. ;re>"ently lea'e space $!r 'ery (rie$ c!++ents !r descripti!ns.
i. Unless the $!r+ is created )ith a 'ery speci$ic patient p!p"lati!n in +ind.
all!) $!r a &eneral assess+ent !$ the patient.
=. I$ there are n! standardiAed +eth!ds !$ d!c"+entin& the in$!r+ati!n
deri'ed $r!+ y!"r assess+ent !$ the patient. all!) r!!+ $!r )ritin&.
3. ;!r+s )ill in$l"ence practice. s! +a3e s"re t! incl"de ite+s that are
(elie'ed essential t! practice.
l. I$ the sta$$ has (een )ritin& SOAP n!tes. transiti!n $!r the sta$$ )ill (e
easier i$ a SOAP $!r+at is $!ll!)ed (eca"se SOAP is a pr!(le+/s!l'in&
$!r+at and d!c"+entin& "sin& this $!r+at !n a $!r+ assists the sta$$in&
pr!(le+ s!l'in&.
+. ;"ncti!n sh!"ld still (e stated $irst in the s"(=ecti'e and !(=ecti'e p!rti!ns
!$ the n!te $!r+. ="st as )hen )ritin& a SOAP n!te.
C. C!+p"teriAed D!c"+entati!n Pr!&ra+s
,omputerized documentation is still in the stages of development 3ome facilities
have a well-developed program that is tailored to the needs of that facility
%. Ad'anta&es !$ C!+p"teriAed D!c"+entati!n !'er Paper/(ased
D!c"+entati!n:
a. In$!r+ati!n placed in a paper/(ased d!c"+entati!n +ay (e li+ited d"e t!
li+ited space all!)ed $!r in$!r+ati!n in a $!r+ )hile in$!r+ati!n that +ay
(e placed in a c!+p"teriAed d!c"+ent is n!t li+ited.
(. C!+p"ters can als! ha'e all !$ the p!ssi(le tests and +eas"re+ents
a'aila(le. s! the therapist is n!t li+ited (y the tests and +eas"re+ents
a'aila(le !n a &i'en $!r+.
*. S!+e ;eat"res That Ha'e ,een De'el!ped !r are In Sta&es !$ De'el!p+ent
That ill Ba3e C!+p"ters E'en Easier t! Use in the ;"t"re:
a. Data can (e entered (y +a3in& ch!ices and si+ply t!"chin& a styl"s t! the
screen.
> %his ma+es data entry more consistent and does not require +eyboard
competence
(. Data can (e printed in a 'ariety !$ $!r+ats.
> 3ince computerized documentation programs utilize data in a database form,
required data in different forms may be directly placed in corresponding spaces
> It could also allow the therapist to choose certain functional or relevant data to
send to the patient"s physician or other referral source
c. The +edical rec!rd can (e retrie'ed and n!tes )ritten at the patientCs
(edside.
> 3ome healthcare facilities have computers located in every patient"s room or
between every two rooms
> %he therapist may be able to use a noteboo+ computer with him $ her that
contains and $ or can access the patient"s medical record and rehab information
for all the patients the therapist treats
d. All d!c"+entati!n can (e c!+pleted at (edside.
> 1ven outpatient and home healthcare therapists will be able to have a noteboo+
computer with them and be able to transmit $ receive information via modem or
other electronic means
e. Hand)ritin& rec!&niti!n is a $eat"re that )ill (e de'el!ped +!re in the ne4t
$e) years.
> %his will enable the therapist to enter extra notes and information as needed
$. G!ice rec!&niti!n is a $eat"re that )ill als! (e de'el!ped +!re in the ne4t
$e) years.
> %his could completely change methods of data entry, although some caution
must be ta+en in the use of voice-activated methodology while at the patient"s
bedside
&. Char&in& )ill (e a(le t! (e d!ne (y the therapist i++ediately "p!n
c!+pletin& the patientCs treat+ent and )hile he < she c!+pletes !ther
c!+p"teriAed d!c"+entati!n -and the c!+p"ter +ay re+ind the therapist
t! char&e the patient.0
> ,omputerized charging systems exist in many clinics today (oving the charging
to the patient"s bedside, along with all other documentation functions, will greatly
increase therapist efficiency and relieve the repetition in documentation that
some therapists experience today
1. Ite+s t! C!nsider hen L!!3in& at C!+p"teriAed D!c"+entati!n Syste+s:
It is important to consider the needs of the therapists at their individual practice sites
> & system should be flexible enough to fulfill the needs of the therapist at the
individual practice site4 otherwise, the system is not worthwhile
a. C!+p"teriAed d!c"+entati!n syste+s 'ary in their +!(ility. )ei&ht.
$le4i(ility. ease !$ "se. speed !$ data entry. and speed !$ the hard)are.
> &ll of these factors must be considered when purchasing or developing a
computerized system
(. Trainin& ti+e +"st (e ta3en int! c!nsiderati!n )hen y!" disc"ss the c!st
!$ a c!+p"teriAed d!c"+entati!n syste+.
> & system that requires extensive training must also save much time I order to be
cost effective
c. Techn!l!&y is !nly )!rth)hile i$ it +a3es the therapistCs tas3 !$
d!c"+entati!n easier and all!)s hi+ < her t! d! s!+ethin& he < she c!"ld
n!t d! )ith!"t the techn!l!&y.
> /or example, the time spent documenting should be decreased, and spelling
errors or obvious errors in the recording of data should be pointed out to the
therapist automatically for the purpose of immediate correction
d. The )illin&ness. a'aila(ility. and c!st !$ pr!&ra++ers t! c"st!+iAe the
syste+ t! the indi'id"al $acilityCs needs sh!"ld (e in'esti&ated (e$!re
+a3in& a c!++it+ent t! a c!+p"teriAed d!c"+entati!n syste+.
GI. O(tainin& and D!c"+entin& S"(=ecti'e C!ntent
A. Intr!d"cti!n t! the Inter'ie)in& Pr!cess and Re'ie)in& the Bedical Rec!rd
Interviewing is an important s+ill for the clinician to learn
#enerally agreed that D?O of the information needed to clarify the cause of
symptoms is contained within the sub-ective examination
9egin the interview by determining the patient"s chief complaint (,$,:!
2sually is a symptomatic description of the patient (ie, sub-ective sensations
reported, such as fatigue, dizziness, night sweats, fever!
%he interview, especially in the sub-ective data, may also reveal contraindications
to physical therapy treatment or indications for the +ind of treatment that is more
li+ely to be effective
1xample:
& patient examined by a physical therapist last year found that ultrasound was the most
effective method for providing long-term relief of symptoms
Puestioning the patient may also assist the physical therapist in determining the
in-ury stage
#uides the clinician in providing appropriate treatment in the in-ury stage:
a. Ac"te in="ry / sy+pt!+atic relie$.
(. Chr!nic in="ry / +!re a&&ressi'e treat+ent.
c. S"(/ac"te in="ry / c!+(inati!n !$ the a(!'e +eth!ds.
Interviewing the patient and reviewing the patient"s medical record will help the
physical therapist to determine the location and potential significance of any
symptom (including pain!
%he interview format provides detailed information regarding the frequency,
duration, intensity, length, breadth, depth, and anatomic relation as these relate
to the patient"s chief complaint
%he physical therapist will later correlate this information with the ob-ective
findings of the examination to rule out possible systemic origins of symptoms
%he information obtained from the interview guides the physical therapist in either
referring the patient to a physician or in treating the patient in a clinic
,. Inter'ie)in& Techni>"es
&n organized interview format assists the physical therapist in obtaining a
complete and accurate database
2sing the same outline with each patient ensures that all pertinent information
related to previous medical history and current medical problem(s! is included
%his information is especially important when correlating the sub-ective data with
ob-ective findings from the physical examination
%. Open/ended #"esti!ns
Puestions that elicit more than a one-word response
&dvantage: can prevent a false-positive or false-negative response that otherwise
would be elicited by a closed-ended question
'isadvantage: may allow the patient to control the interview through an organ recital
> 5rgan *ecital 6 a patient provides detailed information regarding &)) previously
experienced illnesses and symptoms that may or may not be related to the
current problem$
- 1xample:
.%he pain in my hip started =; years ago when I was a corpsman in the navy standing
on my feet =? hours a day It seems to bother me most when I am having
premenstrual symptoms, such as food cravings or depression (y left leg is longer
than my right leg, and my hip hurts when the scars from by bunionectomy ache %his
pain occurs with any changes in the weather I have a bleeding ulcer that bothers me,
and the pain +eeps me awa+e at night I dislocated my shoulder ; years ago, but I
can lift weights now without any problems"
1xample:
.%ell me why you are here"
*. Cl!sed/ended #"esti!ns
*equire only a .yes" or .no" answer
'isadvantages:
a. Tend t! (e +!re i+pers!nal and +ay set an i+pers!nal t!ne $!r the
relati!nship (et)een the patient and the physical therapist.
(. Li+ited (y the restricti'e nat"re !$ the in$!r+ati!n recei'ed s! that the
patient +ay !nly resp!nd t! the cate&!ry in >"esti!n and +ay !+it 'ital.
("t see+in&ly "nrelated. in$!r+ati!n.
c. Bay elicit $alse/p!siti'e !r $alse/ne&ati'e resp!nses that de'el!p $r!+ the
patientCs atte+pt t! pleas the health care pr!'ider !r t! c!+ply )ith )hat
the patient (elie'es is the c!rrect resp!nse !r e4pectati!n.
1xample:
.'o you have any pain after lying in bed all night:"
1. ;"nnel Techni>"e<;"nnel Se>"ence
9egin with one or two open-ended questions, interrupt patient with a polite statement
if or when patient starts to do an .organ recital", then start as+ing follow-up questions
1xample polite statement for interrupting patient:
.I"m beginning to get an idea of the nature of your problem 8ow I would li+e to obtain some
more specific information"
/ollow-up Puestions - are usually closed-ended questions that characterize
symptoms more clearly
&dvantages:
a. Can p!tentially elicit +!re in$!r+ati!n in a relati'ely sh!rt -5 @ %5 +in"te0
peri!d than a steady strea+ !$ cl!sed/ended >"esti!ns.
(. Can esta(lish an e$$ecti'e $!r"+ $!r tr"st (et)een the patient and physical
therapist.
1xample of funnel sequence:
> 9eginning (open-ended! question:
.Gow does rest affect the pain or symptoms:"
> /ollow-up questions:
.&re your symptoms aggravated or relieved by any activities:"
.If yes, what:"
.Gow has this affected your daily life at wor+ or at home:"
.Gow has this problem affected your ability to care for yourself without assistance (eg,
dress, bathe, coo+, drive!:"
2. Paraphrasin& Techni>"e
%he interviewer repeats information presented by the patient
&dvantage: can assist in fostering effective, accurate communication between the
patient and the physical therapist
1xample:
.Nou"ve told me that the pain is relieved by wal+ing around, is that right: 0hat other activities
or treatment brings you relief from your pain or symptoms:"
If the therapist cannot paraphrase what the patient has said, or is unclear about the
meaning of the patient"s response, clarification is achieved by requesting an example of what
the patient is tal+ing about
C. Inter'ie)in& T!!ls
&re self-assessment forms
&re employed to identify problems, to quantify symptoms, and to demonstrate the
effectiveness of treatment
%here is no single interviewing tool that can be considered to be the best under
all circumstances
(ost common interviewing tool employed, especially for pain, is the (c#ill Pain
Puestionnaire
D. Identi$yin& Data<De+!&raphics
(a-ority of information in Identifying 'ata$'emographics are written in a medical
record or referral before the P% has examined and evaluated the patient thus
Identifying 'ata$'emographics are considered data gathered from the
documentation of other healthcare professionals
%. I+p!rtance !$ the Identi$yin& Data<De+!&raphics:
a. Certain diseases ha'e a speci$ic de+!&raphic characteristic
(. It &i'es an idea !n the 3ind !$ appr!ach a PT )!"ld +a3e )hen
inter'ie)in& and e4a+inin& a patient
c. It helps in anticipatin& s!cial pr!(le+s
d. It $acilitates c!nd"ct !$ epide+i!l!&ic researches. as )ell as $!ll!)/"p
researches
*. Types
a. En"+erated:
8ame: (arciano, #eorge
&ge: ;D yo
&ddress: =? /airlane Qillage, 9rgy #uadalupe, ,ebu ,ity
3ex: R
8ationality: /ilipino
,ivil 3tatus: 3ingle
5ccupation: 1ncoder
*eligion: *oman ,atholic
Gandedness: J
Physiatrist: 'r L )asco
'ate of 1val: 8ovember =>, ;??C
'x: J ,arpal %unnel 3yndrome
(edications: &laxan
P% Imp : Impaired grip ;S to J ,arpal %unnel 3yndrome
5r:
8ame: (arciano, #eorge *eligion: *oman ,atholic
&ge: ;D yo Gandedness: J
&ddress: =? /airlane Qillage, 9rgy
#uadalupe, ,ebu ,ity
Physiatrist: 'r L )asco
'ate of 1val: 8ovember =>, ;??C
3ex: R 'x: J ,arpal %unnel 3yndrome
8ationality: /ilipino (edications: &laxan
,ivil 3tatus: 3ingle P% Imp : Impaired grip ;S to J ,arpal
%unnel 3yndrome 5ccupation: 1ncoder
(. Narrati'e:
,ase of #eorge (arciano, a ;D yo R, single, /ilipino, *oman ,atholic, encoder
currently residing in =? /airlane Qillage, 9rgy #uadalupe, ,ebu ,ity who was evaluated
and referred for P% by 'r L )asco 8ovember =>, ;??C with a diagnosis of J ,arpal
%unnel 3yndrome
E. Statin& the Pr!(le+ !r Dia&n!sis
2sually is stated in a medical record or referral under the heading 'x:
In some facilities, pertinent history or medical information ta+en from the chart is
included in the Problem or 'iagnosis
'x: is included in the Identifying 'ata$'emographics since it is usually obtained
from the documentation of other healthcare professionals
3ome information to be included in the Problem or 'x:
%. Past s"r&eries a$$ectin& the present c!nditi!n<treat+ent
*. Past c!nditi!ns<diseases a$$ectin& the present c!nditi!n<treat+ent
1. Present c!nditi!ns<diseases a$$ectin& the present c!nditi!n<treat+ent
2. Test res"lts a$$ectin& the present c!nditi!n<treat+ent
5. Recent !r past s"r&ery a$$ectin& the present c!nditi!n<treat+ent
1xamples:
'x: J hemiplegia resulting from craniotomy for removal of tumor on ==-=E-?C
FD yo R c J 9T& on ==-D-?C ;S to PQ' Gx of '(
;. ritin& S"(=ecti'e C!ntent
&ny information that the patient or significant other tells the therapist directly
%. I+p!rtance !$ Assessin& S"(=ecti'e In$!r+ati!n:
a. T! plan h!) t! e'al"ate the O(=ecti'e p!rti!n !$ the e4a+inati!n t!
deter+ine )hat tests and +eas"res t! "se
(. T! ="sti$y !r e4plain certain &!als that are set )ith the patient
*. Cate&!riAin& Ite+s as S"(=ecti'e:
a. Anythin& the patient !r si&ni$icant !ther tells the therapist re&ardin&
(. Acti'ities that the patient can n! l!n&er per$!r+ d"e t! the patientCs c"rrent
c!nditi!n -pri!r le'el !$ $"ncti!n0
c. The patientCs hist!ry
d. S!+ethin& a(!"t the patientCs li$estyle !r h!+e sit"ati!n
e. E+!ti!ns !r attit"des
$. G!als
&. C!+plaints
h. Resp!nse t! treat+ent
i. Anythin& rele'ant t! the patientCs case !r present c!nditi!n
1. The "se !$ IPatientC
&cceptable to use .Pt" the first time, but not to be repeated with every sentence
&ssumed, unless otherwise stated, that the information in 3ub-ective came from the
patient
2. Or&aniAati!n:
5rganize by topic
3ubcategories or headings may be used to facilitate searching for information
5. ;re>"ently Used Ger(s in the S"(=ecti'e C!ntent:
3ub-ective content frequently contain a verb which indicates that the statement is
sub-ective and not ta+en from the chart
a. States
(. Descri(es
c. Denies
d. Indicates
e. C<! -c!+plains !$0
6. #"!tin& the Patient Ger(ati+:
&t times, quoting the patient verbatim is the appropriate method of conveying
sub-ective information
3ome reasons for using direct quotes from the patient or significant other:
a. T! ill"strate c!n$"si!n !r l!ss !$ +e+!ry
(. T! ill"strate denial
c. T! ill"strate a patientCs attit"de t!)ard therapy
d. T! ill"strate the patientCs "se !$ a("si'e lan&"a&e
7. Usin& In$!r+ati!n Ta3en $r!+ a ;a+ily Be+(er !r Si&ni$icant Other:
3hould state the exact relation of the patient to the informant
Introduced before the actual statement
8. Ite+s Us"ally Incl"ded in the S"(=ecti'e C!ntent:
a. C<C: -chie$ c!+plaint0
> %here can be only 581 chief complaint
> *elate to patient"s function as much as possible
> If pain, state the following:
i. Onset
ii. L!cati!n
iii. #"ality<character
i'. Pr!&ressi!n
'. Intensity
'i. ;re>"ency
'ii. Garia(ility
'iii. D"rati!n
i4. Bi&rati!n pattern
4. Precipitatin&. a&&ra'atin& and relie'in& $act!rs
4i. E$$ect !n ADL. sleep. )!r3. s!cial and recreati!nal acti'ities
4ii. Treat+ent<+edicati!ns
4iii. Other inter'enti!ns "sed and res"lts
4i'. Ass!ciati!n<relati!nship !$ the pain )ith the !ther sy+pt!+s
(. HPI: -hist!ry !$ present illness0
> 3equence of events from onset of problem up to referral for P%
> &rranged chronologically
> (ay be in narrative or outline form
i. Narrati'e:
Patient was apparently well until three days prior to consultation (P%,! when patient
noted J facial asymmetry with ironing out of wrin+les on the J side of the face %here
was associated inability to close the J eye completely, frequent lacrimation, drooling
of liquid food on the J side of the mouth and difficulty in chewing food with
accumulation on the J side of the oral cavity %here was no Gyperacusis or abnormal
ear discharge Persistence of the problem prompted the patient to consult a
physiatrist one day after the onset Patient was diagnosed to have J 9ell"s Palsy and
Prednisone and %ears 8aturale were prescribed Ge was then referred for P%
ii. O"tline:
C days P%,- noted J facial asymmetry and ironing out of wrin+les
- (M! associated incomplete eye closure J, frequent tearing J, drooling of
liquid food J, difficulty in chewing food on J side of oral cavity
- (-! hyperacusis4 (-! pain4 (-! ear discharge
; days P%,- consulted physiatrist due to persistence
- diagnosed with J 9ell"s Palsy
- prescribed Prednisone and %ears 8aturale
- good compliance with medications
- advised P%
at present - no significant changes noted
> Important *eminders &bout the GPI:
i. C!ntains (!th pertinent $indin&s present and a(sent in the patient
ii. Al)ays descri(es the $"ncti!nal stat"s !$ the patient (e$!re and a$ter the !nset
!$ the illness
iii. B"st (e arran&ed in chr!n!l!&ical !rder
i'. B"st descri(e the clinical c!"rse !$ the illness
c. PBH: -past +edical hist!ry0
> Includes other illnesses that:
i. Are 3n!)n ris3 $act!rs !$ the c"rrent disease
ii. Bay alter the clinical c!"rse !$ the c"rrent illness and th"s a$$ect pr!&n!sis
iii. Bay a$$ect the +ana&e+ent !$ the patient
> 5ther items that may be included here:
i. ;DA
ii. S+!3in& H4.
iii. Drin3in& H4.
i'. Dr"& H4.
d. H;D: -heredit!$a+ilial diseases0
> Presence of illness or state of health in the family (father, mother, brothers, and
sisters! and relatives
e. ;DA: -$!!d and dr"& aller&ies0
$. H!+e Sit"ati!n:
> )iving arrangements
> 'escribes the physical and social aspects of the home
> Includes:
i. S"pp!rt syste+
ii. En'ir!n+ental assess+ent
&. Pt.Cs Li$estyle:
> Personal, social, and environmental history
> (ay include:
i. S+!3in& H4:
ii. Drin3in& H4:
iii. Dr"& H4:
i'. Daily Acti'ities:
'. !r3 Acti'ities:
'i. Recreati!nal Acti'ities:
'ii. Pre/+!r(id Stat"s:
h. Pt.Cs G!al:
> &nticipated goals and expected outcomes for the patient$client
9. Special C!nsiderati!ns Re&ardin& S"(=ecti'e C!ntent in a Pediatric !r
O(stetric Case
Gave additional components
a. Pediatric Cases
> Includes:
i. ,irth and +aternal hist!ry
- If patient is still a neonate, these are included in the GPI
- Information obtained are:
i.a N"+(er !$ days p!st/deli'ery i$ ne!nate
i.( A&e !$ &estati!n -AOG0 at the ti+e !$ deli'ery and<!r ter+
i.c Nat"re !$ deli'ery
i.d APGAR sc!re at the ti+e !$ (irth
i.e Place !$ deli'ery and )h! attended t! the deli'ery
i.$ Presence<a(sence !$ +aternal illnesses. accidents and !ther pr!(le+s
d"rin& the pre/natal. perinatal and p!st/natal peri!ds
i.& Presence<a(sence !$ pre/natal care. )ith )h!+ and h!) re&"larly
i.h Inta3e !$ any +edicati!ns. recreati!nal dr"&s !r a(!rti$acients )hen the
+!ther )as pre&nant )ith the (a(y
i.i Attit"de !$ the parents t!)ard the pre&nancy
ii. N"triti!nal hist!ry
- Important in pediatric conditions that result from undernutrition or malnutrition
iii. I++"niAati!n hist!ry
- Important in pediatric conditions that may be prevented through immunization
i'. De'el!p+ental hist!ry
- Important in pediatric conditions presenting with developmental delay
(. O(stetric Cases
> Includes:
i. Parity
ii. O(stetric sc!res
GII. O(tainin& and D!c"+entin& O(=ecti'e C!ntent I: Intr!d"cti!n t! O(=ecti'e
Data and the Syste+s Re'ie)
A. Intr!d"cti!n t! O(=ecti'e Data
%he ob-ective part of the note is the section in which the results of measurements
performed and the therapist"s ob-ective observations of the patient are recorded
5b-ective data are the measurable or observable information used to plan patient
treatment
%esting procedures that produce ob-ective data are repeatable
,. Cate&!riAin& Ite+s as O(=ecti'e Data
&n item is considered ob-ective if:
%. It is part !$ the patientCs hist!ry ta3en $r!+ the +edical rec!rd and rele'ant t!
the pr!(le+.
8ot all facilities include information from the medical record
1xample:
5: Gx: &3G', ,G/, ,5P' 3$P fx ()! hip c prosthesis insertion = yr
*. It is a res"lt !$ the therapistCs !(=ecti'e +eas"re+ents !r !(ser'ati!ns.
(ust be measurable and reproducible data
&re written in the ob-ective part of a note but usually are summarized versions of the
following:
a. Data(ases
(. ;l!) sheets
c. Charts
d. Speci$ic assess+ent $!r+s
If none of the above-mentioned forms are available, only pertinent (important! data
are to be written in the ob-ective part
1xample:
5: &*5(: 08) throughout 21s U )1s except ?V-=;?V ()! shoulder flexion noted
1. It is part !$ the treat+ent &i'en t! the patient.
'ata obtained here are written in other notes aside from the evaluation notes (interim
(progress! notes, discharge notes$summaries, turnover notes, and referral notes!
Particularly:
a. B!di$icati!ns "sed
(. N"+(er !$ repetiti!ns t!lerated
c. Pain relie'ed !r ca"sed
%his provides information to anyone who might treat the patient as to what was done
in a treatment session on a certain date
&lso done to inform both those reimbursing the treatment and those who might read
the medical record as a legal document of what was specifically done with the patient
1xample:
5: P% (x received:
= PL( to (*! shoulder using #r I inferior glides, #r II distraction
; &*5( exercises to (*! shoulder flexion-extension, abduction-adduction U medial
rotation-lateral rotation, =? reps W C sets each c F-secs isometrics X end-ranges
C Ice massage to anterior, posterior, lateral U superior aspects of (*! shoulder W F
mins
2. It is a patient ed"cati!n acti'ity.
2sually written in other notes aside from the evaluation notes
(any agencies accrediting patient care facilities are very interested in written
evidence of what P%s teach patients and families
1xample:
5: Patient 1ducation: *eceived instruction in home exercise program U was indep in same
program (attached!
C. Or&aniAati!n !$ O(=ecti'e Data
2sing categories or headings ma+e information organized, easy to read, and
easy to find
,ategories of headings can be based on:
%. Types !$ tests and +eas"res per$!r+ed.
Gelpful when a patient has deficits on multiple areas or has a generalized problem
1xample:
&mbulation
%ransfers
9alance
*5(
3trength
3ensation
*. Areas !$ the (!dy and $"ncti!nal s3ills.
Gelpful when a patient has deficits only on one or two parts of the body
1xample:
&mbulation
&')
21s
)1s
%run+
Placing ob-ective data into categories or headings depends on:
%. The dia&n!sis and de$icits !$ the indi'id"al patient.
%he therapist categorizes information in the manner that they deem most efficient
and organized
2sed in some facilities only
*. ;acility r"les and &"idelines !n d!c"+entati!n.
%he therapist categorizes information on &)) patients in the same manner despite
differences in diagnoses and deficits between patients
%he usual basis of placing items under a category$heading
(ethods of using categories or headings:
%. ;"ncti!nal cate&!ries $irst (e$!re n!n$"ncti!nal cate&!ries.
%he therapist presents functional categories before the nonfunctional categories
(ay also be presented with the functional category first then outlining directly after
the functional deficit the nonfunctional deficit(s! that contributed to the functional deficit
(ost preferred method by other readers of the note (eg physicians, third-party
payers, et al!
*. N!n$"ncti!nal cate&!ries $irst (e$!re $"ncti!nal cate&!ries.
%he therapist has to present first the nonfunctional categories that lead to a
functional deficit
0ithin any individual category$heading, the following rules are followed:
%. Or&aniAe in$!r+ati!n in the +!st l!&ical !rder p!ssi(le.
*. E!ints are descri(ed !ne at a ti+e. "s"ally in a cephal!/ca"dal +anner and
$r!+ pr!4i+al t! distal.
D. C!++!n Bista3es in Rec!rdin& O(=ecti'e Data
3ome of the most common mista+es in recording ob-ective data are:
%. ;ail"re t! state the a$$ected part.
*. ;ail"re t! p"t ite+s in +eas"ra(le ter+s.
If an item cannot be stated in measurable terms, the word .appears" instead of .is"
should be used
3hould be used cautiously as third-party payers do not reimburse for intervention
that .appears" necessary
1. ;ail"re t! state the type !$ )hate'er it is that is (ein& +eas"red !r !(ser'ed.
E. S!+e Speci$ics Re&ardin& Rec!rdin& O(=ecti'e Data
0hen using scales with numerical values, always include the normal value to
ma+e the -ob of other people rearing the note for third-party payers easier
1xample:
((%: C$F versus fair
0hen using scales with analog values, always include the scale or rating system
used and the definition for each value
1xample:
'eep %endon *eflexes: (5Yareflexia$absent4 M-hyporeflexia4 MMYnormoreflexia4 MM
MYhyperreflexia MMMMYabnormal with = - C beats of clonus: MMMMMYabnormal with sustained
clonus!
1xample using a combined numerical$analog scale:
Pain: F$=? using visual analog pain scale (Q&P3! (?Yno pain: =Yminimum perceivable pain4
FY moderate pain4 =?Yworst possible pain!
&bbreviations U (edical %erminology
%. Bini+iAe "se !$ a((re'iati!ns and "se !nly "ni'ersally accepted a((re'iati!ns
!r the $acilityJs appr!'ed a((re'iati!ns.
*. Use !nly appr!priate +edical ter+in!l!&y )ith c!rrect spellin&.
;. The Syste+s Re'ie)
& briefer limited examination of:
%. The anat!+ical and physi!l!&ical stat"s !$ the cardi!'asc"lar<p"l+!nary.
inte&"+entary. +"sc"l!s3eletal. and ne"r!+"sc"lar syste+s and
*. The c!++"nicati!n a(ility. a$$ect. c!&niti!n. lan&"a&e. and learnin& style !$
the patient<client
%he physical therapist especially notes how these affect the ability to initiate, sustain,
and modify purposeful movement for performance of an action, tas+, or activity that is pertinent
to function
&lso assists the physical therapist in identifying possible problems that require
consultation with or referral to another provider
G. C!+p!nents !$ the Syste+s Re'ie)
%he systems review includes the following:
%. Cardi!'asc"lar<P"l+!nary Syste+:
Geart rate
*espiratory rate
9lood pressure
1dema
*. Inte&"+entary Syste+
3+in integrity
3+in color
Presence of scar formation
1. B"sc"l!s3eletal Syste+
#ross symmetry
#ross range of motion
#ross strength
Geight
0eight
2. Ne"r!+"sc"lar Syste+
#ross coordinated movement (eg balance, locomotion, transfers, and transitions!
5. C!++"nicati!n A(ility. A$$ect. C!&niti!n. Lan&"a&e. and Learnin& Style
&bility to ma+e needs +nown
,onsciousness
5rientation (person, place, and time!
1xpected emotional$behavioral responses
)earning preferences (eg, teaming barriers, education needs!
GIII. O(tainin& and D!c"+entin& O(=ecti'e C!ntent II: Tests and Beas"res in
Physical Therapy
A. Intr!d"cti!n t! Tests and Beas"res
%he means of gathering data about the patient$client
Physical therapists individualize the selection of tests and measures based on
the history they ta+e and systems review they perform, rather than basing their
selection on a previously determined medical diagnosis
/rom the history and systems review, the physical therapist determines
patient$client needs and generates diagnostic hypotheses that may be further
investigated by selecting specific tests and measures %hese are used to rule out
causes of impairment and functional limitations4 establish a diagnosis, prognosis,
and plan of care4 and select interventions
%he tests and measures that are performed as part of an initial examination
should be only those that are necessary to:
%. C!n$ir+ !r re=ect a hyp!thesis a(!"t the $act!rs that c!ntri("te t! +a3in& the
c"rrent le'el !$ patient<client $"ncti!n less than !pti+al. and
*. S"pp!rt the physical therapistCs ="d&+ents a(!"t appr!priate inter'enti!ns.
anticipated &!als. and e4pected !"tc!+es.
9efore, during, and after administering the tests and measures, physical
therapists gauge responses, assess physical status, and obtain a more specific
understanding of the condition and the diagnostic and therapeutic requirements
%he physical therapist may decide to use one, more than one, or portions of
several specific tests and measures as part of the examination %hese are based
on the purpose of the visit, the complexity of the condition, and the directions
ta+en in the clinical decision-ma+ing process
&s the examination progresses, the physical therapist may identify additional
problems that were not uncovered by the history and systems review and may
conclude that other specific tests and measures or portions of other specific tests
and measures are required to obtain sufficient data to perform an evaluation,
establish a diagnosis and a prognosis, and select interventions %he examination
therefore may be as brief or as lengthy as necessary %he physical therapist may
decide that a full examination is necessary and then select appropriate tests and
measures ,onversely, the physical therapist may conclude from the history and
systems review that further examination and intervention are not required, that
the patient$client should be referred to another practitioner, or both
%ests and measures vary in the precision of their measurements4 however, useful
data may be generated through various means /or instance, data generated
from either a gross muscle test of a group of muscles or from a very precise
manual muscle test could be used to re-ect the hypothesis that muscle
performance is contributing to a functional deficit 3imilarly, even though a
functional assessment instrument may quantify a large number of &') or I&'), it
may fail to detect the inability to perform a particular tas+ and activity that is most
important to the patient
%he tests and measures that are selected by the physical therapist should yield
data that are sufficiently accurate and precise to allow the therapist to ma+e a
correct inference about the patient"s$client"s condition %he selection of specific
tests and measures and the depth of the examination vary based on:
%. A&e !$ the patient<client
*. Se'erity !$ the pr!(le+
1. Sta&e !$ rec!'ery
2. Phase !$ reha(ilitati!n
5. H!+e. c!++"nity. !r )!r3 -=!(<sch!!l<play0 sit"ati!n. and
6. Other rele'ant $act!rs.
&fter the initial examination, tests and measures are used:
%. T! d!c"+ent chan&es in patient<client stat"s. and
*. T! indicate achie'e+ent !$ the !"tc!+es that are the end/p!ints !$ care and
there(y ens"re ti+ely and appr!priate dischar&e.
,. hat is Beas"re+entD
&ccording to &P%&"s 3tandards for %ests and (easurements in Physical %herapy
Practice:
%he numeral assigned to an ob-ect, event, or person 5* the class (category! to
which an ob-ect, event, or person is assigned to according to rules
5btaining measurements is an everyday part of physical therapy practice
Physical therapists obtain many different types of measurements 1xamples of
which are:
%. Assessin& the +a&nit"de !$ a patientCs rep!rt !$ pain
*. #"anti$yin& +"scle per$!r+ance !r ran&e !$ +!ti!n
1. Descri(in& the 'ari!"s characteristics !$ a patientCs &ait pattern
2. Cate&!riAin& the assistance that a patient re>"ires
%he physical therapist collects data through many different methods, such as:
%. Inter'ie)in&
*. O(ser'ati!n
1. #"esti!nnaires
2. Palpati!n
5. A"sc"ltati!n
6. C!nd"ctin& per$!r+ance/(ased assess+ents
7. Electr!physi!l!&ical testin&
8. Ta3in& ph!t!&raphs and +a3in& !ther 'ide!&raphic rec!rdin&s
9. Rec!rdin& data "sin& scales. inde4es. and in'ent!ries
%:. O(tainin& data thr!"&h the "se !$ techn!l!&y/assisted de'ices
%%. Ad+inisterin& patient<client sel$/assess+ent tests
%*. Re'ie)in& patient<client diaries and l!&s
Physical therapists use tests and measures to obtain measurements, which they
then use to interpret to identify:
%. Si&ns and sy+pt!+s !$ path!l!&y<path!physi!l!&y -disease. dis!rder. !r
c!nditi!n s"ch as:
Loint tenderness
Pain
1levated blood pressure with activity
8umbness and tingling
1dema
*. I+pair+ents s"ch as:
&erobic capacity
&nthropometric characteristics
&rousal, attention, and cognition
,irculation
,ranial and peripheral nerve integrity
1rgonomics and body mechanics
#ait, locomotion, and balance
Integumentary integrity
Loint integrity and mobility
(otor function
(uscle performance
8euromotor development and sensory integration
Posture
*ange of motion
*eflex integrity
3ensory integrity
Qentilation and respiration$gas exchange
1. ;"ncti!nal li+itati!ns s"ch as:
0or+ (-ob$school$play!, community, and leisure integration or reintegration (including
I&')!
1rgonomics and body mechanics
3elf-care and home management (including &') and I&')!
2. Disa(ilities s"ch as:
Inability to engage in community, leisure, social, and wor+ roles
5. De'ice and e>"ip+ent need and "se s"ch as:
&ssistive and adaptive devices
5rthotic, protective, and supportive devices
Prosthetic devices
6. ,arriers s"ch as:
1nvironmental, home, and wor+ (-ob$school$play! barriers
In the evaluation process, the physical therapist synthesizes the examination
data to establish the diagnosis and prognosis (including the plan of care! %he
data gathered through the use of tests and measures during initial examination
provide information used for determining anticipated goals and expected
outcomes %hese data may:
%. Indicate initial a(ilities in per$!r+in& acti!ns. tas3s. and acti'ities
*. Esta(lish criteria $!r place+ent decisi!ns. and
1. Identi$y le'el !$ sa$ety in per$!r+in& a partic"lar tas3 !r ris3 !$ in="ry )ith
c!ntin"ed per$!r+ance )ith !r )ith!"t de'ices and e>"ip+ent
*eexamination at regular intervals during an episode of care enables the
physical therapist to measure and document:
%. Chan&es in patient<client stat"s. and
*. The pr!&ress that the patient<client is +a3in& t!)ard the anticipated &!als and
e4pected !"tc!+es
C. Relia(ility and Galidity !$ Beas"re+ents
0henever possible, physical therapists should use measurements whose
reliability and validity have been documented in the peer-reviewed literature
*eliable and valid measurements enable physical therapists to gauge:
%he certainty of their examination data, and
%he appropriate scope of inferences that may be drawn from those data
*eliability and validity are properties of a measurement, not the test or measure
used to obtain the measurement
& measurement is reliable only under certain conditions and for certain types of
patients$clients and is valid only for a particular purpose
*eliability and validity have not yet been reported for every measurement used
by physical therapists 2se of measurements without established reliability and
validity may be appropriate, however, especially when there are no alternatives 6
and provided that the physical therapist is aware that those measurements may
be prone to error and that, therefore, decisions made using those measurements
may be less certain
%. Relia(ility !$ Beas"re+ents
&ssessing a measurement"s reliability is an attempt to identify sources of error &
measurement is said to be reliable when it is consistent time after time, with as little variation as
possible 9ecause all measurements have some error, however, the clinician must determine
whether a measurement is useful or whether there is so much error that the measurement is
rendered useless for a particular purpose
%wo (a-or %ypes of *eliability:
> %hese help to determine how much error exists in a particular measurement
a. Test/retest Relia(ility
> %he consistency of repeated measurements that are separated in time when
there is no change in what is being measured
> Indicates the stability of a measurement
(. Intra/rater<Inter/rater Relia(ility
i. Intra/rater Relia(ility
- Indicates the degree to which measurements that are obtained by the same physical therapist at
different times will be consistent
ii. Inter/rater Relia(ility
- Indicates the degree to which measurements obtained by multiple therapists will be consistent
- 1specially important 6 if different physical therapists obtain different measurements when
measuring the same phenomenon, the usefulness of the measurements is limited
5ther /orms of *eliability:
a. Parallel/$!r+ Relia(ility
> *elates to measurements that are obtained by using different versions of the
same test or measure
(. Internal C!nsistency<H!+!&eneity
> *elates to measurements that are obtained by using tests or measures with
multiple items or parts, where each part is supposed to measure one, and only
one, concept
*. Galidity !$ Beas"re+ents
%he degree to which a useful (meaningful! interpretation can be inferred from a
measurement
/orms of Qalidity:
a. ;ace Galidity
> 1xists when the measurement seems to reflect what is supposed to be measured
6 but it does not depend on evidence
> 1xample: goniometric measurements 6 have face validity as measurements of
-oint position
(. C!ntent Galidity
> 1stablishes the degree to which a measurement reflects the domain of interest
> 1xample: instruments to assess -oint pain 6 might generate data only regarding
pain on motion, not pain at rest or factors that aggravate or alleviate pain
c. C!nstr"ct Galidity
> & theoretical form of validity that is established on the basis of evidence that a
measurement represents the underlying concept of what is to be measured
> 1xample: the overall concept of .motor function" is the construct that underlies
any particular test or measure of motor function
> %here are no direct tests of construct validity %heoretical evidence of construct
validity is often provided by demonstrating convergence if tests or measures
believed to represent the same construct are highly related
> 1xample of ,onvergence: a test of motor function, based on a particular concept
of what .motor function" means, should correlate highly with other tests or
measures based on similar conceptions of .motor function" or on concepts that
are closely related to .motor function," such as .dexterity and coordination"
> 1vidence of construct validity is also found when there is a low association, or
divergence, between a test or measure of one particular construct and other tests
or measures reflecting distinctly different, or even unrelated, constructs
> 1xample of 'ivergence: there should be low association between a test of .motor
function" and tests and measures that are based on the concepts of .aerobic
conditioning" or .range of motion"
d. C!nc"rrent Galidity
> 1xists when an inferred interpretation is -ustified by comparing a measurement
with supporting evidence that was obtained at approximately the same time as
the measurement being validated
> 1xample: developers of a new balance test might compare the measurements
obtained using the new test to those obtained using an established balance test
involving one-legged stance
> %he comparative method of establishing concurrent validity is particularly
relevant for self-assessment instruments
e. Predicti'e Galidity
> 1xists when an inferred interpretation is -ustified by comparing a measurement
with supporting evidence that is obtained at a later point in time and examines
the -ustification of using a measurement to say something about future events or
conditions
> Tnowing the predictive validity of a measurement may facilitate the identification
of achievable outcomes and increase the efficiency of discharge planning
> 1xample: predictive validity of a measurement of functional capacity might be
established by verifying whether the measurement indicates the li+elihood of
return to wor+
> Predictive validity may also provide the physical therapist of information about
the value of selecting particular tests or measures for the examination, such as:
i. Sensiti'ity !$ a Beas"re+ent
- Indicates the proportion of individuals with a positive finding who already have or will have a
particular characteristic or outcome
- %he positive predictive validity of a measurement
ii. Speci$icity !$ a Beas"re+ent
- Indicates the proportion of individuals with a negative finding who truly do not or will not have a
particular characteristic or outcome
- %he negative predictive validity of a measurement
D. Clinical Utility !$ a Beas"re+ent
& physical therapist must also consider the clinical utility of the test or measure
for a particular purpose Physical therapists should consider:
%. Precisi!n !$ the data yielded (y a test !r +eas"re
*. hether it )ill +eet the needs !$ the sit"ati!n
1. The ti+e in'!l'ed in ad+inisterin& a test !r +eas"re
2. The c!st !$ ad+inisterin& a test !r +eas"re. and
5. Patient<client $act!rs s"ch as t!lerance !$ testin& p!siti!ns and s"ita(ility !$
the test !r +eas"re t! a partic"lar p!p"lati!n
3ome measurements are only gross measurements #ross measurements may
be useful for a population screen but may not be useful for identifying a small
change in patient$client status after intervention
%he measurements used by the physical therapist should always be sensitive
enough to detect the degree of change expected as a result of intervention
E. Cate&!ries !$ Tests and Beas"res
%here are a total of twenty-four (;<! categories of tests and measures that
physical therapists commonly perform
1ach categorization of tests and measures includes:
%. General de$initi!n and p"rp!se !$ the test and +eas"re.
& definition and purpose of the test and measure is provided &ll tests and measures
produce information used to identify the possible or actual causes of difficulties during
performance of essential everyday activities, wor+ tas+s, and leisure pursuits 3election of tests
and measures depends on the findings of the history and systems review %he examination may
indicate, for instance, that tests should be conducted while the patient$client performs specific
activities In all cases, the purpose of tests and measures is to ensure the gathering of
information that will lead to evaluation, diagnosis, prognosis, and selection of appropriate
interventions
*. Clinical indicati!ns.
1xamples of clinical indications are identified during the history and systems review
are provided to indicate the use of tests and measures 3pecial requirements may prompt the
physical therapist to perform tests and measures &ll tests and measures are appropriate in the
presence of:
a. I+pair+ent. $"ncti!nal li+itati!n. disa(ility. de'el!p+ental delay. in="ry. !r
s"spected !r identi$ied path!l!&y that pre'ents !r alters per$!r+ance !$
daily acti'ities. incl"din& sel$/care. h!+e +ana&e+ent. )!r3
-=!(<sch!!l<play0. c!++"nity. and leis"re acti!ns. tas3s. !r acti'ities.
(. Re>"ire+ents !$ e+pl!y+ent that speci$y +ini+"+ capacity $!r
per$!r+ance.
c. Identi$ied ris3 $act!rs.
d. Need t! initiate pr!&ra+s that pr!+!te health. )ellness. !r $itness.
1. Tests and +eas"res. -+eth!ds and techni>"es0
1xamples of specific tests and measures are provided
2. T!!ls "sed $!r &atherin& data.
& listing of tools used for collecting data is provided
5. Data &enerated.
%ypes of data that may be generated from the tests and measures are listed
6. Other In$!r+ati!n that +ay (e re>"ired $!r the e4a+inati!n.
Includes:
a. ;indin&s !$ !ther pr!$essi!nals
(. Res"lts !$ dia&n!stic i+a&in&. clinical la(!rat!ry. and electr!physi!l!&ical
st"dies
c. ;ederal. state. and l!cal )!r3 s"r'eillance and sa$ety rep!rts and
ann!"nce+ents. and
d. Rep!rted !(ser'ati!ns !$ $a+ily +e+(ers. si&ni$icant !thers. care&i'ers.
and !ther interested pe!ple
%he list of these categories of tests and measures, including the information
stated above, may be seen in &ppendix IQ
;. I+p!rtant Tests and Beas"res in GeneraliAed C!nditi!ns
,oncentrate examination of the patient on the items listed below each
generalized condition
%. B"sc"l!s3eletal C!nditi!ns
5bservation of:
a. General attit"de !$ patient
(. General p!st"re
c. illin&ness t! +!'e
d. Gait
e. O('i!"s de$!r+ities -a(n!r+al c"r'at"res. =!int s"(l"4ati!n. asy++etrical
(!dy c!nt!"rs. s)ellin&. and c!l!r and te4t"re !$ s3in0
> If the above are present, a more detailed examination is necessary
Palpation
a. Areas !$ pain and tenderness
(. Areas !$ restricti!n
c. S)ellin&
d. Anat!+ical !rientati!n !$ str"ct"res
&*5(
P*5(
3trength
/lexibility (including -oint play and muscle length tests!
/unctional tests (&') and I&')!
3pecial tests
5ther diagnostic procedures
*. Ne"r!+"sc"lar C!nditi!ns
&rousal, attention, and cognition
,ommunication
/unctional tests (&') and I&')!
(otor control
%one
3ensation and perception
/lexibility
1. Cardi!p"l+!nary C!nditi!ns
,ardiovascular diagnostic tests and procedures
Pulmonary diagnostic tests and procedures
2. Inte&"+entary C!nditi!ns
Integumentary integrity and condition (including vascular compromise, trauma,
disease, and scar tissue!
In any condition, always chec+ for presence or ris+ of secondary complications
3pecial ,onditions:
*equire additional tests and measures
%. Pediatric C!nditi!ns
'evelopmental milestones
*. Geriatric C!nditi!ns
#enerally, all categories of tests and measures are included
IK. Ele+ents !$ Patient<Client Bana&e+ent in Assess+ent and D!c"+entin&
Assess+ent C!ntent in a SOAP ;!r+at
A. Intr!d"cti!n
%hree elements of patient$client management are incorporated in formulating the
&ssessment portion %hese are:
%. E'al"ati!n
*. Dia&n!sis
1. Pr!&n!sis
%he &ssessment portion of a 35&P note includes four sections that, together,
provide the reader with the therapist"s reasoning for goals and treatment %hese
sections are:
%. Pr!(le+ List
*. L!n&/Ter+ G!als<E4pected ;"ncti!nal O"tc!+es
1. Sh!rt/Ter+ G!als
2. I+pressi!ns<S"++ary
,. Ele+ents !$ Patient<Client Bana&e+ent in Assess+ent
%he following elements of patient$client management are present in the
&ssessment process:
%. E'al"ati!n
%he organization and interpretation of data
Physical therapists ma+e evaluations (clinical -udgments! that are based on the data
gathered from the examination (history, systems review, and tests and measures! that are
synthesized to establish the diagnosis, prognosis, and plan of care
/actors that influence the complexity of the evaluation process include:
a. Clinical $indin&s
(. E4tent !$ l!ss !$ $"ncti!n
c. S!cial c!nsiderati!ns
d. O'erall physical $"ncti!n and health stat"s
%he evaluation reflects:
a. Chr!nicity !r se'erity !$ the c"rrent pr!(le+
(. P!ssi(ility !$ +"ltisite !r +"ltisyste+ in'!l'e+ent
c. Presence !$ pree4istin& syste+ic c!nditi!ns !r diseases
d. Sta(ility !$ the c!nditi!n
Physical therapists also consider:
a. Se'erity and c!+ple4ity !$ the c"rrent i+pair+ents and the pr!(a(ility !$
pr!l!n&ed i+pair+ent. $"ncti!nal li+itati!n. and disa(ility
(. The li'in& en'ir!n+ent
c. P!tential dischar&e destinati!ns
d. S!cial s"pp!rt
1valuation encompasses all sections in the &ssessment portion of a 35&P note but
is mainly the process in considering the significant findings (Problem )ist!
*. Dia&n!sis
%he application of a label
Physical therapists typically use diagnostic labels that identify the impact of a
condition on function at the level of the system (especially the movement system! and at the
level of the whole person
%he assigning of a diagnostic label through the classification of a patient$client within
a specific practice pattern is a decision reached as a result of a systematic process %his
process includes integrating and evaluating the data that are obtained during the examination
(history, systems review, and tests and measures! to describe the patient$client condition in
terms that will guide the physical therapist in determining the prognosis, plan of care, and
intervention strategies %hus the diagnostic label indicates the primary dysfunctions toward
which the physical therapist directs interventions %he diagnostic process enables the physical
therapist to verify the individual needs of each patient$client to similar individuals who are
classified in the same pattern while also capturing the unique concerns of the patient$client in
meeting those needs in a particular sociocultural and physical environment
If the diagnostic process does not yield an identifiable cluster (eg, of signs or
symptoms, impairments, functional limitations, or disabilities!, syndrome, or category, the
physical therapist may administer interventions for the alleviation of symptoms and remediation
of impairments &s in all other cases, the physical therapist is guided by patient$client responses
to those interventions and may determine that a reexamination is in order and proceed
accordingly
%he ob-ective of the physical therapist"s diagnostic process is the identification of
discrepancies that exist between the level of function that is desired by the patient$client and the
capacity of the patient$client to achieve that level In carrying out the diagnostic process,
physical therapists may need to obtain additional information (including diagnostic labels! from
other professionals In addition, as the diagnostic process continues, physical therapists may
identify findings that should be shared with other professionals (including referral sources! to
ensure optimal care If the diagnostic process reveals findings that are outside the scope of the
physical therapist"s +nowledge, experience, or expertise, the physical therapist refers the
patient$client to an appropriate practitioner
(a+ing a diagnosis requires the clinician to collect and sort data into categories
according to a classification scheme relevant to the clinician who is ma+ing the diagnosis
%hese classification schemes should meet the following criteria:
a. Classi$icati!n sche+es +"st (e c!nsistent )ith the (!"ndaries placed !n
the pr!$essi!n (y la) -)hich +ay re&"late the applicati!n !$ certain types
!$ dia&n!stic cate&!ries0 and (y s!ciety -)hich &rants appr!'al $!r
+ana&in& speci$ic types !$ pr!(le+s and c!nditi!ns0.
(. The test and +eas"res necessary $!r c!n$ir+in& the dia&n!sis +"st (e
)ithin the le&al p"r'ie) !$ the health care pr!$essi!nal.
c. The la(el "sed t! cate&!riAe a c!nditi!n sh!"ld descri(e the pr!(le+ in a
)ay that directs the selecti!n !$ inter'enti!ns t!)ard th!se inter'enti!ns
that are )ithin the le&al p"r'ie) !$ the health care pr!$essi!nal )h! is
+a3in& the dia&n!sis.
%he preferred practice patterns in &P%&"s #uide to Physical %herapist Practice
describe the management of patients who are grouped by clusters of impairments that
commonly occur together, some of which are associated with health conditions that impede
optimal function 1ach pattern represents a diagnostic classification %he pattern title therefore
reflects the diagnosis 6 or impairment classification 6 made by the physical therapist %he
diagnosis may or may not be associated with a health condition for patients$clients who are
classified into that pattern
%he physical therapist uses the classification scheme of the preferred practice
patterns to complete a diagnostic process that begins with the collection of data (examination!,
proceeds through the organization and interpretation of data (evaluation!, and culminates in the
application of a label (diagnosis!
'iagnostic labels are placed in the Impressions$3ummary section of the &ssessment
portion of a 35&P note
%he list of these Physical %herapy diagnostic labels may be seen in &ppendix Q
1. Pr!&n!sis -incl"din& Plan !$ Care0
a. Pr!&n!sis
> %he determination of the predicted optimal level of improvement in function and
the amount of time needed to reach that level
> (ay also include a prediction of levels of improvement that may be reached at
various intervals during the course of therapy
> Prognosis is documented in the &ssessment part of a 35&P note as the
outcomes and goals ()ong-%erm #oals$1xpected /unctional 5utcomes and
3hort-%erm #oals!
(. Plan !$ Care
> ,onsists of statements that specify the anticipated goals and expected
outcomes, predicted level of optimal improvement, specific interventions to be
used, and proposed duration and frequency of the interventions that are required
to reach the anticipated goals and expected outcomes
> %herefore describes:
i. Speci$ic patient<client +ana&e+ent -Inter'enti!ns0
ii. Ti+in& $!r patient<client +ana&e+ent $!r the epis!de !$ physical therapy care
-G!als0
> %he plan of care is the culmination of the examination, diagnostic, and prognostic
processes It is established in collaboration with the patient$client and is based on
the data gathered from the history, systems review, and tests and measures and
on the diagnosis determined by the physical therapist In designing the plan of
care, the physical therapist analyzes and integrates the clinical implications of the
severity, complexity, and acuity of the pathology$pathophysiology (disease,
disorder, or condition!, the impairments, the functional limitations, and the
disabilities to establish the prognosis and prediction about the li+elihood of
achieving the anticipated goals and expected outcomes
> %he plan of care identifies anticipated goals and expected outcomes, ta+ing into
consideration the expectations of the patient$client and appropriate others (If
required, the anticipated goals and expected outcomes may be expressed as
short-term and long-term goals! &nticipated goals and expected outcomes are
the intended results of patient$client management and indicate the changes in
impairments, functional limitations, and disabilities and the changes in health,
wellness, and fitness needs that are expected as the result of implementing the
plan of care %he anticipated goals and expected outcomes also address ris+
reduction, prevention, impact on societal resources, and patient$client
satisfaction %he anticipated goals and expected outcomes in the plan should be
measurable and time limited
> %he plan of care includes the anticipated discharge plans In consultation with
appropriate individuals, the physical therapist plans for discharge and provides
for appropriate follow-up or referral %he primary criterion for discharge is the
achievement of anticipated goals and expected outcomes 0hen physical
therapy services are terminated prior to achievement of anticipated goals and
expected outcomes, patient$client status and the rationale for termination are
documented /or patients$clients who require multiple episodes of care, periodic
follow-up is needed over the life span to ensure safety and effective adaptation
following changes in physical status, caregivers, environment, or tas+ demands
> %hus, Plan of ,are encompasses the &ssessment and Plan portions of a 35&P
note
> 8ote: In the course of examining the patient$client and establishing the diagnosis
and prognosis, the physical therapist may find evidence of physical abuse or
domestic violence 2niversal screening for domestic violence is increasingly
becoming a statutory requirement
C. D!c"+entin& Assess+ent C!ntent in a SOAP ;!r+at
3ections of the &ssessment portion of a 35&P note:
%. Pr!(le+ List
Provides a list of the ma-or problems as written in the 3ub-ective and 5b-ective parts
of a 35&P note
3ome facilities do not include this portion but is becoming a reference point for other
healthcare professionals, third-party payers, and others who read the medical record and need
a quic+ overview of the patient"s physical therapy problems, -ust as physical therapists loo+ to
physician"s impressions for a summary of the patient"s significant medical problems
*elationships to other portions of the 35&P note:
a. S"(=ecti'e and O(=ecti'e
> %he problem list includes the ma-or areas that were not 08) when the
3ub-ective interview and 5b-ective testing were performed
(. L!n&/Ter+ G!als<E4pected ;"ncti!nal O"tc!+es
> 2sually each problem listed in a 35&P note is covered by a long-term
goal$expected functional outcome
3teps to formulating the Problem )ist:
a. -Prere>"isite0 rite the S and O p!rti!ns !$ the n!te.
(. Re'ie) the S and O p!rti!ns !$ the n!te. =!ttin& d!)n !r hi&hli&htin&
$indin&s that are n!t NL and that can (e in$l"enced !r chan&ed (y
physical therapy inter'enti!n.
> (edical or psychiatric problems do not belong in the physical therapy problem
list
> Gowever, discussion as to how medical or psychiatric problems affect the
patient"s potential or actual performance in physical therapy should be included
in the Impressions$3ummary part of the &ssessment portion of the note
c. Set pri!rities as t! )hich pr!(le+ is the +!st i+p!rtant. the ne4t
i+p!rtant. and s! $!rth.
> Involves -udgment on the part of the physical therapist
d. List the physical therapy pr!(le+s in !rder !$ pri!rity.
> )ist in functional terms, if possible, and in a general manner, since this list is a
summary of the more specific details included under 3 and 5
*. L!n&/Ter+ G!als<E4pected ;"ncti!nal O"tc!+es
3tate the final product to be achieved by physical therapy
5nce the problem list is established, the patient"s long-term goals are set
*easons for writing goals:
a. T! help the physical therapist plan treat+ent t! +eet the speci$ic needs
and pr!(le+s !$ a patient
(. T! pri!ritiAe treat+ent and +eas"re e$$ecti'eness
c. T! assist )ith +!nit!rin& c!st e$$ecti'eness -$!r p"rp!ses !$ third/party
pay+ent0
d. T! c!++"nicate the therapy &!als $!r a patient t! !ther healthcare
pr!$essi!nals
%he structure of a goal (&9,'"s of goal setting!:
a. A"dience
> 0ho will exhibit the s+ill:
> &lmost always the patient is the audience
> ,an also be a family member or the patient with a family member
> 81Q1* the physical therapist
> #oals are patient-oriented, not therapist oriented
(. ,eha'i!r
> 0hat will the audience do:
> &lways a verb, often followed by the ob-ect of the behavior
> /requently, as a )%#, is a functional behavior
> %he ob-ect of the behavior must be something that can be measured or
described accurately so that the physical therapist can document when goals are
achieved
> &lways stated using action verbs .9e" or .+now" are not acceptable
.'emonstrate", .list", and .state" are acceptable
c. C!nditi!n
> 2nder what circumstances or conditions:
> %he position, the equipment, and so forth that must be provided or be available
for the patient to perform the behavior
d. De&ree
> Gow well will the behavior be done:
> %he specific amount of improvement to be seen
> 2sually the longest portion of a goal
> *equirements as to degree:
i. The de&ree !$ per$!r+ance +"st (e realistic. +eas"ra(le. !r !(ser'a(le.
ii. B"st na+e a speci$ic ti+e span in )hich the &!al )ill (e achie'ed. -Needs
clinical e4perience t! deter+ine0
iii. B"st (e e4pressed in ter+s !$ $"ncti!n. )hen p!ssi(le. -N!t re>"ired in s!+e
$acilities ("t all!)s !ther readers t! "nderstand the rati!nale (ehind the &!al0
> 8umber of feet, number of repetitions, muscle grades, degrees of *5(
,riteria for revision of )%#:
a. The patientCs c!nditi!n chan&es and )ill n!t all!) pr!&ressi!n t! the
$"ncti!nal le'el !ri&inally set.
(. The patientCs c!nditi!n chan&es and )ill all!) pr!&ressi!n (ey!nd the
$"ncti!nal le'el !ri&inally set.
c. The ti+e span set is n! l!n&er appr!priate and sh!"ld (e re'ised.
*elationships to other portions of the 35&P note:
a. Pr!(le+ List
> 2sually, a )%# may be set for each problem
> &cceptable if one )%# may address several problems
> Important to consider several aspects in the patient interview (3 portion! when
setting )%#
(. Sh!rt/Ter+ G!als
> 3%# are written as steps toward achieving )%#
1xpected functional outcomes are )%# In functional outcomes report (/5*! format,
only functional goals are stated %he focus is on what the patient can and cannot do due to a
physical impairment, not the impairment
1. Sh!rt/Ter+ G!als
Interim steps along the way to achieving )%#
5nce )%# are determined, 3%# are set
3tructure of 3%# is same as to )%# (&9,'"s of goal setting!
,riteria for revision of 3%#:
a. Ti+e peri!d +enti!ned in a pre'i!"s STG has passed.
(. The patient has achie'ed the STG.
*elationships to other portions of the 35&P note:
a. L!n&/Ter+ G!als<E4pected ;"ncti!nal O"tc!+es
> 3%# are based on the determined )%#
(. Plan
> 0hen a treatment plan is set up, some sort of treatment to wor+ toward each of
the 3%# must be included
3%# in /5*:
> /acilities differ in use of 3%# in /5*
2. I+pressi!ns<S"++ary
Part of the &ssessment portion of a 35&P note for drawing correlations in the 3, 5,
&, and P potions of the note and -ustifying decisions for goals and treatment plan 3ome of the
following items may be noted in this part:
a. Inc!nsistencies
(. E"sti$icati!n $!r the &!als set. the treat+ent plan. and<!r clari$icati!n !$ the
pr!(le+
c. Disc"ssi!n !$ the patientCs pr!&ress in physical therapy
d. PatientCs reha(ilitati!n p!tential
e. Di$$ic"lty in !(tainin& in$!r+ati!n
$. S"&&esti!n !$ $"rther testin&<treat+ent needed
&. Physical therapy dia&n!sis
h. Other
K. ;!r+"latin&. De'el!pin&. and D!c"+entin& a Plan !$ Care
A. Intr!d"cti!n
%wo elements of patient$client management are incorporated in formulating the
Plan portion %hese are:
%. Pr!&n!sis -speci$ically Plan !$ Care0
*. Inter'enti!n
%here are requirements and guidelines in formulating a good treatment plan
%he initial plan of care must be continually monitored and evaluated
,. Ele+ents !$ Patient<Client Bana&e+ent In Plannin&
%he following elements of patient$client management are present in the Planning
process:
%. Pr!&n!sis -speci$ically Plan !$ Care as disc"ssed in the Assess+ent p!rti!n0
*. Inter'enti!n
%he purposeful interaction of the physical therapist and the patient$client and, when
appropriate, with other individuals involved in patient$client care, using various physical
therapy procedures and techniques to produce changes in the condition that are consistent with
the diagnosis and prognosis
'ecisions about interventions are contingent on:
a. ti+ely +!nit!rin& !$ patient<client resp!nse
(. pr!&ress +ade t!)ard achie'in& the anticipated &!als and e4pected
!"tc!+es
,oordination, communication, and documentation and patient$client-related
instruction are provided as part of intervention for all patients$clients %he use of procedural
interventions, however, varies because those interventions are selected, applied, or modified
according to examination and reexamination findings and the anticipated goals and expected
outcomes for a particular patient$client in a specific diagnostic group
Physical therapist intervention encourages functional independence, emphasizes
patient$client-related instruction, and promotes proactive, wellness-oriented lifestyles %hrough
appropriate education and instruction, the patient$client is encouraged to develop habits that will
maintain or improve function, prevent recurrence of problems, and promote health, wellness,
and fitness
,omponents (full descriptions may be seen in &ppendix QI!
a. C!!rdinati!n. C!++"nicati!n. and D!c"+entati!n
> &dministrative and supportive processes intended to ensure that patients$clients
receive appropriate, comprehensive, efficient, and effective quality of care from
admission through discharge
i. C!!rdinati!n/ the )!r3in& t!&ether !$ all parties in'!l'ed )ith the patient<client
ii. C!++"nicati!n/ the e4chan&e !$ in$!r+ati!n
iii. D!c"+entati!n/ any entry int! the patient<client rec!rd that identi$ies the care
!r ser'ice pr!'ided
> Physical therapists are responsible for coordination, communication, and
documentation across all settings for all patients$clients
> &dministrative and support processes may include:
i. addressin& re>"ired $"ncti!ns. s"ch as ad'anced care directi'es.
indi'id"aliAed ed"cati!nal plans -lEPs0. !r indi'id"aliAed $a+ily ser'ice
plans -I;SPs0. in$!r+ed c!nsent . and +andat!ry c!++"nicati!n and rep!rtin&
-e.&.. patient ad'!cacy and a("se rep!rtin&0
ii. ad+issi!n and dischar&e plannin&
iii. case +ana&e+ent
i'. c!lla(!rati!n and c!!rdinati!n )ith a&encies
'. c!++"nicati!n acr!ss settin&s
'i. c!st/e$$ecti'e res!"rce "tiliAati!n
'ii. data c!llecti!n. analysis. and rep!rtin&
'iii. d!c"+entati!n acr!ss settin&s
i4. interdisciplinary tea+)!r3
4. re$errals t! !ther pr!$essi!nals !r res!"rces
(. Patient<client/related Instr"cti!n
> %he process of informing, educating, or training patients$clients families,
significant others, and caregivers intended to promote and optimize physical
therapy services
> Instruction may be related to:
i. C"rrent c!nditi!n
ii. Speci$ic i+pair+ents. $"ncti!nal li+itati!ns. !r disa(ilities
iii. Plan !$ care
i'. Need $!r enhanced per$!r+ance
'. Transiti!n t! a di$$erent r!le !r settin&
'i. Ris3 $act!rs $!r de'el!pin& a pr!(le+ !r dys$"ncti!n
'ii. Need $!r health. )ellness. !r $itness pr!&ra+s
> Physical therapists are responsible for patient$client-related instruction across all
settings for all patients$clients
c. Pr!ced"ral Inter'enti!ns
> %he physical therapy procedures and techniques, which include:
i. Therape"tic e4ercise
ii. ;"ncti!nal trainin& in sel$/care and h!+e +ana&e+ent -incl"din& ADL
and IADL0
iii. ;"ncti!nal trainin& in )!r3 -=!(<sch!!l<play0. c!++"nity. and leis"re
inte&rati!n and reinte&rati!n -incl"din& IADL. )!r3 hardenin&. and )!r3
c!nditi!nin&0
i'. Ban"al therapy techni>"es
'. Prescripti!n. applicati!n. and. as appr!priate. $a(ricati!n !$ de'ices and
e>"ip+ent -assisti'e. adapti'e. !rth!tic. pr!tecti'e. s"pp!rti'e. and pr!sthetic0
'i. Air)ay clearance techni>"es
'ii. Inte&"+entary repair and pr!tecti!n techni>"es
'iii. Electr!therape"tic +!dalities
i4. Physical a&ents and +echanical +!dalities
> Physical therapists select interventions based on the complexity and severity of
the clinical problems In determining the prognosis, the interventions to be used,
and the li+elihood of an intervention"s success, physical therapists must also
consider the differences between the highest level of function of which the
individual is capable and the highest level of function that is li+ely to be habitual
for that individual Patients$clients are more li+ely to achieve the anticipated goals
and expected outcomes that are determined with the physical therapist if they
perceive a need to function at the highest level of their ability 6 and if they were
motivated to function habitually at that level %hus understanding the difference
between what a person currently does and what a person potentially could do is
essential in ma+ing a prognosis and identifying realistic, achievable goals and
outcomes Physical therapists ultimately must abide by the decisions of the
patient$client regarding actions, tas+s, and activities that will be incorporated into
a daily routine and regarding what constitutes a meaningful level of function
> %he physical therapist"s selection of procedural interventions should be based
on:
i. E4a+inati!n $indin&s -incl"din& th!se !$ the hist!ry. syste+s re'ie). and tests
and +eas"res0. an e'al"ati!n. and a dia&n!sis that s"pp!rts physical therapy
inter'enti!n
ii. A pr!&n!sis that is ass!ciated )ith i+pr!'ed !r +aintained health stat"s
thr!"&h ris3 red"cti!n. health. )ellness. and $itness pr!&ra+s. !r the
re+ediati!n !$ i+pair+ents. $"ncti!nal li+itati!ns. !r disa(ilities
iii. A plan !$ care desi&ned t! i+pr!'e. enhance. and +a4i+iAe $"ncti!n thr!"&h
inter'enti!ns !$ appr!priate intensity. $re>"ency. and d"rati!n t! achie'e
anticipated &!als and e4pected !"tc!+es e$$iciently "sin& a'aila(le res!"rces.
> %he physical therapist selects, applies, or modifies these interventions based on
anticipated goals and expected outcomes that have been developed with the
patient$client &nticipated goals and expected outcomes relate to specific
impairments, functional limitations, or disabilities4 signs or symptoms4 ris+
reduction$prevention4 and health, wellness, or fitness needs %he anticipated
goals and expected outcomes listed in the plan of care should be measurable
and time-specific
> In con-unction with coordination, communication, and documentation and
patient$client-related instruction, three categories of procedural interventions form
the core of most physical therapy plans of care:
i. Therape"tic e4ercise
ii. ;"ncti!nal trainin& in sel$/care and h!+e +ana&e+ent -incl"din& ADL
and IADL0
iii. ;"ncti!nal trainin& in )!r3 -=!(<sch!!l<play0. c!++"nity. and leis"re
inte&rati!n and reinte&rati!n -incl"din& IADL. )!r3 hardenin&. and )!r3
c!nditi!nin&0
> %he other categories of procedural interventions may be used when the
examination, evaluation, diagnosis, and prognosis indicate their necessity
> /actors that influence the complexity of both the examination process and the
selection of interventions may include:
i. Chr!nicity !r se'erity !$ c"rrent c!nditi!n
ii. Le'el !$ c"rrent i+pair+ent and pr!(a(ility !$ pr!l!n&ed i+pair+ent.
$"ncti!nal li+itati!n. !r disa(ility
iii. Li'in& en'ir!n+ent
i'. B"ltisite !r +"ltisyste+ in'!l'e+ent
'. O'erall physical $"ncti!n and health stat"s
'i. P!tential dischar&e destinati!ns
'ii. Pree4istin& syste+ic c!nditi!ns !r diseases
'iii. S!cial s"pp!rts
i4. Sta(ility !$ the c!nditi!n
> %hrough routine monitoring and reexamination, the physical therapist determines
the need for any alteration in an intervention or in the plan of care %he
interventions used, including their frequency and duration, are consistent with
patient$client needs and physiological and cognitive status, anticipated goals and
expected outcomes, and resource constraints %he independent performance of
the procedure or technique by the patient$client (or significant other, family, or
caregiver! is encouraged following instruction in safe and effective application
> /ailing to intervene appropriately to prevent illness or to habilitate or rehabilitate
patients$clients with impairments, functional limitations, and disabilities leads to
greater costs for both the person and society %he #uide provides administrators
and policy ma+ers with the information they need to ma+e decisions about the
cost-effectiveness of physical therapist intervention
C. Treat+ent Plannin&
&n effective treatment program begins with a good initial plan %he initial plan
consists of the proposed treatment goals or ob-ectives, and the corresponding
interventions that will be used to achieve each of the treatment goals
*equirements of a #ood %reatment Plan
%. It addresses all the identi$ied pr!(le+s. It is rele'ant.
%here must be a specific goal and treatment procedure for each of the problems in
the problem list %his is true even for problems that will be referred to other team members
%he plan should also set specific goals and treatment procedures for potential
problems &ll potential secondary problems that are li+ely to occur in the patient, in his lifetime,
must be enumerated in the problem list and a corresponding treatment goal and preventive
measure must be included in the plan
0henever possible, the treatment should reflect the same +ind of priority as that of
the problem list %his will lead to effective time management and will be discussed further below
*. It is realistic.
8o matter how impressive and complete a P%$5% plan is, it will be of no value if it
cannot be implemented in full 0hen designing the initial plan the therapist must ma+e sure
everything written there can be implemented without difficulty
3ome #uide Puestions to &rrive at a *ealistic Plan:
a. Can the sh!rt/ter+ &!als (e achie'ed )ithin the &i'en ti+e $ra+eD
(. Can the entire treat+ent pr!&ra+ (e c!+pleted )ithin the sched"led
app!int+ent !$ the patientD
c. D!es the "nit<$acility ha'e all the +aterials and e>"ip+ents needed t!
i+ple+ent the pr!&ra+ and e'al"ate the !"tc!+eD
d. Is the a'aila(le +anp!)er s"$$icient and c!+petent in deli'erin& the
rec!++ended +ana&e+entD I$ n!t. can the therapist s"per'ise and<!r train
sta$$ t! i+ple+ent the pr!&ra+ e$$ecti'elyD
e. Can the patientCs c!!perati!n (e depended "p!n partic"larly $!r the h!+e
pr!&ra+D Can the patient a$$!rd t! pay $!r the pr!&ra+D
1. It is appr!priate t! the pr!(le+. as )ell as appr!priate t! the patient<client
and<!r case.
%his is self-explanatory %he treatment goal will wor+ at the specific problem while
the intervention will accomplish the goal
&side from ma+ing a plan that is appropriate to the problem, the plan should also be
designed according to the needs of the patient %he holistic approach of rehabilitation ma+es
each treatment program unique %he patient plays an active role and participates in treatment
planning %herefore, unli+e most medical or surgical treatment programs the rehabilitation
program cannot be pac+aged as a single program$protocol and prescribed to all cases with the
same diagnosis
2. It is c!st/e$$ecti'e.
5nly a patient and his$her family are in a position to decide whether they can afford
to undergo treatment or not & therapist should never ma+e this decision for them4 neither
should the cost of treatment deter a therapist from planning the program best suited to the
patient
%he responsibility of the therapist is to come up with an appropriate and complete
program that will achieve the desired results within the shortest possible time and at the least
cost without compromising the quality of the results %his rule applies to all patients regardless
of stature It is unethical to withhold a good treatment strategy from a patient who is assumed to
be of low stature and to over-charge or design complicated but unnecessary procedures for
patients assumed to be of high stature
%he ideal program must always be presented to the patient and his$her family %he
advantage of such program and required duration and cost should also be presented %he
patient and his$her family will decide, based on the given information, if they can mange to
complete the program and if they can afford it If the patient$family verbalizes a problem with
regard to compliance and$or finances, the therapist must now present alternative plans and
explain the advantages and disadvantages of these alternatives compared to the ideal program
&n excellent and highly efficient therapist is always able to come out with an effective program
suited to the needs of all patients
5. It leads t! e$$ecti'e ti+e +ana&e+ent.
In actual practice, most clinics$facilities will have only a limited number of therapists
In fact, most clinics are managed only by one therapist &ssistants, aides, and$or interns are
available to help in the implementation of the program but evaluation, planning, and monitoring
are responsibilities of the therapist alone %he most difficult tas+ of the therapist is in supervising
the staff and ma+ing sure that the prescribed treatment plan is being carried out properly %his
-ob is made easier when the plan is written in such a way that when the staff follows each step
in the plan he$she:
a. ill 3n!) e4actly )hat t! d!.
(. ill &i'e each treat+ent pr!ced"re in the c!rrect se>"ence.
c. ill c!+plete the pr!&ra+ at the sh!rtest p!ssi(le ti+e and )ith!"t err!r.
d. Can i++ediately i+ple+ent alternati'es in the e'ent that circ"+stances
pre'ent hi+<her $r!+ carryin& !"t the !ri&inal pr!&ra+.
e. Can identi$y indicat!rs that )ill s"&&est that the treat+ent is &!in& )ell !r
n!t.
$. I++ediately 3n!)s )hen he<she has t! re$er the case t! the therapist.
0hen each case is handled efficiently, more patients can be accommodated and
each patient is assured of a safe, well-implemented, and appropriate program
6. It is dyna+ic.
,ommon 5bservations in ,linics$/acilities *egarding Patient %reatment:
a. There is a tendency in therapists in clinics<$acilities t! c!n'ert e'al"ati!n.
treat+ent. and +!nit!rin& pr!ced"res int! Ipre/desi&nedC $i4ed pr!t!c!ls.
(. There is als! a tendency in therapists in clinics<$acilities t! +aintain a
patient !n the !ri&inal treat+ent plan $!r the entire d"rati!n !$ the
treat+ent !r c!n$ine the+sel'es t! the prescripti!n "ntil the sched"led
ree4a+inati!n<ree'al"ati!n.
%he therapist must never limit or confine his$her evaluation and treatment plan to a
fixed protocol or maintain a patient on a fixed plan even if the clinic$facility set-up strictly
requires the prescription of a physiatrist %he therapist can always refer the case bac+ to the
physiatrist with a report on the recent change in a patient"s status and recommend any
change(s! in the patient"s management
& dynamic plan may change at any time It is not limited by norms but is very sound
and can always be -ustified & dynamic plan arouses the interest of the patient and his$her family
and solicits their cooperation un+nowingly
'ynamism may not be limited to the treatment plan alone 'ynamism can also be
applied to the treatment approach
#uidelines in Prescription 0riting:
%. It is "s"ally (est t! ta("late the Initial Plan.
0hen the problem list is complete and prioritized, tabulating the plan against each of
the problems will result in a complete and prioritized treatment plan
*. Al)ays +a3e and )rite a c!+plete prescripti!n.
1. hene'er p!ssi(le )rite the !rders in the desired se>"ence in )hich it sh!"ld
(e carried !"t.
1ven if the entire plan is tabulated, always do an enumerated prescription
2. hen re>"estin& $!r e'al"ati!n pr!ced"res and<!r prescri(in& treat+ent
pr!ced"res speci$y the desired techni>"e in sit"ati!ns )here !ther
appr!aches are als! "sed.
5. ,e as speci$ic as p!ssi(le )hen )ritin& the &!als.
%he therapist has to reevaluate the treatment program regularly %he basis for the
effectiveness of the program will be the outcome It is easier to assess the program when the
desired outcome has been specified
6. As +"ch as p!ssi(le incl"de the ti+e li+it !r ti+e $ra+e in the prescripti!n.
H!)e'er. (e as acc"rate as p!ssi(le in y!"r predicti!ns.
%he time frame must have a sound basis 'o not be too pessimistic in setting the
time frame either
7. Al)ays ta3e int! c!nsiderati!n the &!als !$ the patient and his<her $a+ily.
%his is especially important under the following circumstances:
a. The pr!&ra+ )ill re>"ire a chan&e in li$estyle $!r the patient and<!r his<her
$a+ily.
(. The c!!perati!n !$ the patient and<!r $a+ily is essential $!r s"ccess.
c. The $a+ily has 'ery li+ited $inances !r has li+ited ins"rance c!'era&e.
d. The disa(ility has (een present $!r a l!n& peri!d and patient s"ddenly
decides t! "nder&! reha(ilitati!n and<!r there is a hist!ry !$ Id!ct!r/
sh!ppin&C. B!st !$ these patients ha'e "nrealistic &!als.
e. hen e'al"ati!n !$ the patient sh!)s that therape"tic inter'enti!n can (e
!$ 'ery little help t! the patient.
8. hene'er p!ssi(le $!c"s and<!r e+phasiAe !n $"ncti!nal &!als and !"tc!+es.
%o -ustify the need to undergo treatment in countries whether insurance companies
pay for the cost of treatment, there must be a significant improvement in the function of the
patient %his usually includes the ability to perform &'), ambulate independently, and in some
occasions the ability to return to gainful employment
D. ritin& Plan C!ntent in a SOAP ;!r+at
%he Plan portion of the 35&P note contains the plan for the patient"s treatment
5ne or more treatments exist to achieve each of the 3%#s
Information %hat (ust 9e Included 2nder Plan:
%. ;re>"ency per day !r )ee3 that the patient )ill (e seen.
*. The treat+ent that the patient )ill recei'e.
%he amount of specificity may depend on the setting
1. I$ a dischar&e s"++ary. )here the patient is &!in& and the n"+(er !$ ti+es
the patient )as seen in therapy.
5ther Information /requently Included 2nder Plan:
%. The l!cati!n !$ the treat+ent.
*. The treat+ent pr!&ressi!n.
1. Plans $!r $"rther assess+ent !r reassess+ent.
2. Plans $!r dischar&e.
5. Patient and $a+ily ed"cati!n.
&ny home program plans or what was taught to the patient or the patient"s family &
signed and dated copy must be attached to the note, if possible
6. E>"ip+ent needs and e>"ip+ent !rdered<s!ld t! the patient -i$ a dischar&e
s"++ary0.
7. Re$erral t! !ther ser'ices? i$ there are plans t! c!ns"lt )ith the patientCs
physician re&ardin& $"rther treat+ent !r re$erral.
%he Plan portion of the note describes the plan for the patient"s treatment (what
the patient will receive! %his differs from the situation of describing the treatment
and reaction to treatment in the 5b-ective portion of the note If treatment is
addressed in the 5b-ective portion of the note, it may include specifics of what
was done with the patient that day and$or the patient"s reaction to treatment
*elationship to 3hort-%erm #oals:
5nce the short-term goals are set, a treatment plan is then set up to achieve each of
the short-term goals 5ne intervention may achieve more than one goal In fact, it is
advantageous and economically sound to establish the treatment program to achieve the goals
most efficiently 0hen setting up a treatment program, each short-term goal, the patient"s
allotted time for therapy, the patient"s endurance level, and the patient"s level of boredom must
be considered
%hings to ,onsider 0hen *ecording the %reatment Plan:
%. B!dalities:
a. hich +!dalityD
(. hereD
c. H!) l!n&D
d. IntensityD
e. hat p!siti!nD
*. A+("lati!n:
a. DistanceD
(. Le'el !$ assistanceD
c. De'ice-s0D
d. Ti+eD
e. ei&ht/(earin& stat"sD
$. Type !$ &ait patternD
1. E4ercise:
a. E4tre+ity !r tr"n3D
(. TypesD
c. Repetiti!nsD
d. P!siti!nD
e. E>"ip+ent "sedD
$. B!di$icati!nsD
&. A+!"nt !$ resistance &i'enD
h. H!+e pr!&ra+sD
i. ,rie$ &!al<rati!nale state+ent
ii. Ill"strati!ns
iii. P!siti!n
i'. Directi!ns -3eep lan&"a&e si+ple and in patient ter+s0
'. Repetiti!ns and ti+es<day
'i. Pr!&ressi!n
'ii. E>"ip+ent
'iii. Preca"ti!ns
%he Plan portion of a /5* note does not differ from this format
E. E'al"ati!n and B!nit!rin& !$ the Initial Plan
1ven the best of plans may not yield the expected results In patients, this is
usually due to an unexpected change in the clinical course of the patient and to
socioeconomic circumstances that were not thoroughly investigated
%o be able to detect such unexpected courses in a patient, the therapist should
already prepare a scheme that will facilitate evaluation and monitoring /or
beginners, this is done best through a tabulation of the most important and
relevant indicators of successful treatment
KI. ritin& Other N!tes
A. Treat+ent N!tes:
&re records of treatment or non-treatment of a patient$client
1ach treatment note is written directly after the treatment of the patient$client or when
the physical therapist has seen the patient$client and the patient$client has refused or treatment
is put on hold
1very treatment session usually includes some elements of patient$client
management, specifically:
a. E4a+inati!n
(. E'al"ati!n
c. Pr!&n!sis -incl"din& plan !$ care0
d. Inter'enti!n
%hus, every daily note written is a partial interim$progress note
Is usually written in a 35&P format and may also be written in a narrative format
%. Initial PT N!te:
Is a record of the first treatment session of the patient$client
Is written only after the initial evaluation (I1! of the patient has been documented
35&P format:
Initial P% 8ote
date
Initially seen U treated today the case of (Pt"s 8ame!, a (age! y$o (sex! from
(address! who was referred for P%* due to ('x$P% Imp!
3: usually, only c$c: is included here
5: usually included here are:
3ignificant 5: findings (eg, Q3, *5(, ((%!
Initial P% (x *eceived: including patient education$instruction
&: Initial Problem )ist:
i. L -is (ased !n the pr!(le+ list !$ the initial e'al"ati!n -IE0.0
P: In cases where change in future intervention is indicated, the appropriate
changes are documented here including patient education$instruction
In cases where no change in future intervention is indicated, write .,ont c
previously described program" or .,ont c same program"
3ignature
8ame
'esignation
8arrative format:
Initial P% 8ote
date
Initially seen U treated today the case of (Pt"s 8ame!, a (age! y$o (sex! from
(address! who was referred for P%* due to ('x$P% Imp!
c$c:
(Pertinent ob-ective findings!
Initial Problem )ist:
%. L -is (ased !n the pr!(le+ list !$ the initial e'al"ati!n -IE0.0
P% (x *eceived: (complete with parameters including patient education$instruction!
%. L
Q3: a %x 'uring %x p %x
9P (mm Gg! (location, method, position!
P* (bpm! (location, method, position!
** (cpm! (pattern, regularity, position!
*eaction to %x: (3ub-ective$5b-ective findings after treatment session!
3ignature
8ame
'esignation
*. S"ccessi'e PT N!tes:
Is a record of each treatment session of the patient$client
35&P format:
P% 8ote
date
3: usually, only c$c: is included here ,hanges in 3: content may also be noted
5: usually included here are:
3ignificant 5: findings (eg, Q3, *5(, ((%!
P% (x *eceived: (including patient education$instruction!
&: Problem )ist:
i. L -s!+e $acilities +ay re>"ire this p!rti!n speci$ically i$ it is t! (e addressed
in the present treat+ent sessi!n. Pr!(le+-s0 t! (e addressed $!r the sessi!n
are placed "nder this headin&.0
#oal(s! of the 'ay$3ession:
%. L -s!+e $acilities re>"ire this p!rti!n. G!al-s0 t! (e achie'ed $!r the present
treat+ent sessi!n +ay (e placed here.0
P: In cases where change in future intervention is indicated, the appropriate
changes are documented here including patient education$instruction
In cases where no change in future intervention is indicated, write .,ont c
previously described program" or .,ont c same program"
3ignature
8ame
'esignation
8arrative format:
P% 8ote
date
*eaction to %x: (3ub-ective$5b-ective information before U after previous treatment
session!
Q3: a %x 'uring %x p %x
9P (mm Gg! (location, method, position!
P* (bpm! (location, method, position!
** (cpm! (pattern, regularity, position!
Pt received the same P% (x as of (date!-Z(if pt received the same previous
intervention!
P% (x *eceived:-Z(if pt received a new set of P% intervention or P% intervention
was modified or added to, and including patient education$instruction!
%. L
3ignature
8ame
'esignation
%reatment notes are still written even if:
a. Patient<client re$"sed treat+ent.
(. Treat+ent is !n h!ld.
> 0ith corresponding reason for refusal or why treatment is on hold
,. E'al"ati!n N!tes
%his is written to document progress of the patient as well as to determine the
effect of the management given
3hould never be a mere duplication of the initial evaluation (I1!
2ses the 35&P format
%. Interi+<Pr!&ress N!tes
/requency of writing interim$progress notes ultimately depends on clinical experience
of the therapist basing on the case of the patient
3ome facilities specify their own rules regarding frequency of interim$progress note
documentation
3:
> 2sed if there is an update of previous information or if there is relevant new
information to convey
> 1xamples:
i. S"(=ecti'e in$!r+ati!n addressed in pre'i!"sly set &!als -e.&.. pain0
ii. S"(=ecti'e resp!nse t! treat+ent
iii. PatientCs c!+pliance and<!r !ther health c!nditi!ns d"rin& the )ee3
i'. PatientCs le'el !$ $"ncti!nin& at h!+e
5:
> 8ot every category addressed in the I1 of the patient is included
> 5nly information obtained while reassessing the patient during treatment
sessions is included
> If a significant ob-ective finding is unchanged, it is acceptable to address the
category and state that it is unchanged Gowever, the unchanged status should
be briefly described
> 'ata used for comparison purposes can also be included
> Information addressed in interim$progress notes should include areas addressed
in the last set of short-term goals written
> &gain, +now the requirements of both the facility and the third-party payers
3ome third-party payers require listing both the treatment received and the
patient"s reaction to the treatment %his is listed in the 5: portion under *eaction
to %x:
&: Problem )ist:
> & problem is usually listed only if:
i. It is a ne) pr!(le+
ii. It has (een res!l'ed
> %he documenting therapist is referring to the problem
&: )%#$1xpected /unctional 5utcomes:
> 2sually are not addressed unless they:
i. Ha'e (een achie'ed
ii. Need t! (e re'ised
&: 3%#:
> %he therapist refers to the previous 3%#s and sets new 3%#s if they have been
achieved
> If previous 3%#s have not been achieved, state reason and either:
i. Reset the &!al t! +a3e it +!re reas!na(le
ii. Restate the &!al as a &!al t! (e achie'ed (y the ne4t interi+<pr!&ress n!te t!
(e )ritten
&: Impressions$3ummary:
> Included if necessary
P:
> 'epends on the set goals
> If new goals require revision of planned intervention, documentation of planned
intervention is necessary
> If same goals or new goals do not require revision of planned intervention, the
following phrases may be used:
i. C!nt. c pre'i!"sly descri(ed pr!&ra+.
ii. C!nt. c sa+e pr!&ra+.
> Patient education$instruction is included here
*. Re/e'al"ati!n -RE0
%his is written for cases that need re-evaluation$re-examination due to:
a. Ne) clinical $indin&s
(. ;ail"re t! resp!nd t! physical therapy inter'enti!ns
Gas a similar format as with an initial evaluation (I1!, except:
> In the sub-ective portion only the chief complaint is re-written, all other portions of
the sub-ective contents are not necessarily written but some cases may require a
change in some of the sub-ective data (case to case basis!
C. T"rn!'er N!tes
& special type of notes that are made whenever a therapist has to permanently or
temporarily transfer the care of the patient to another therapist
,ommonly used by P% interns due to regular change in rotation
&gain, should never be a mere duplication of the initial evaluation (I1!
%. End!rse+ent<O"t&!in& N!tes
%he turnover notes of the outgoing therapist
(ay be titled as .1ndorsement 8ote" or .5utgoing 8ote" depending on the facility
Is best performed with a pertinent re-evaluation of the patient on the last treatment
session before endorsement
(ay be presented in:
a. Narrati'e $!r+ i$ 'ery little in$!r+ati!n is (ein& end!rsed
(. C!+(ined narrati'e and en"+erati!n $!r+at i$ there is a l!n& pr!(le+ list
3hould contain a summary of the following:
a. Pertinent de+!&raphic data
(. S"++ary !$ the patient data(ase -S and O0 $!c"sin& !n pertinent $indin&s
c. Pr!(le+s identi$ied in the patient
d. The c!rresp!ndin& treat+ent plan
e. S"++ary !$ the clinical c!"rse !$ the patientCs case speci$yin&:
$. The n"+(er !$ treat+ent sessi!ns and d"rati!n !$ the pr!&ra+
&. A s"++ary !$ the pr!&ress !$ the patient
h. Pertinent chan&es in the treat+ent
i. The latest physical e4a+inati!n $indin&s !$ the patientCs case
35&P format:
1ndorsement 8ote
date
1ndorsing (patient"s name!, a (age! y$o (sex! from (address! who was referred for
P%* due to ('x$P% Imp!
3: usually, only c$c: U GPI: from the I1 up to the last treatment session are included
here
5: usually included here are:
3ignificant 5: findings (eg, Q3, *5(, ((%! from the I1 U compared to a
pertinent re-evaluation performed on the last treatment
P% (x *eceived: (complete with parameters U changes in intervention
throughout the episode of care including patient education$instruction!
,ompliance c P%:
%otal P% %x 3essions: (starting from the initial P% session!
&: ,urrent Problem )ist:
i. L -deter+ined as t! the pertinent re/e'al"ati!n per$!r+ed !n the last treat+ent
sessi!n pri!r t! end!rse+ent.0
P: ,urrent P% (x: (complete with parameters, and including patient
education$instruction!
%. L
/requency of %x sessions: (including schedule!
Precautions: (including special considerations!
Plans for /urther Intervention: (when necessary including patient
education$instruction!
3ignature
8ame
'esignation
8arrative format:
1ndorsement 8ote
date
1ndorsing (patient"s name!, a (age! y$o (sex! from (address! who was referred for
P%* due to ('x$P% Imp!
(c$c:!
(3ummary of GPI:!
(/indings of pertinent re-evaluation performed on the last treatment session!
,urrent Problem )ist:-Z(state only problems noted upon the last %x session!
%. L
P% (x *eceived: (included if there was any change in intervention, and including
patient education$instruction!
%. L
,urrent P% (x: (complete with parameters!
%. L
(,ompliance c P%:!
(%otal %x 3essions starting from the initial P% session!
(Progression of patient"s condition!
(Plans for further intervention and patient education$instruction!
(Precautions U special considerations!
(/requency of treatment U treatment schedule!
3ignature
8ame
'esignation
& good and complete endorsement$outgoing note should:
a. Gi'e le&al pr!tecti!n t! the !"t&!in& therapist
> In the event that the patient develops complications or problems during the
course of therapy, the outgoing evaluation will confirm that such event did not
happen during the outgoing therapist"s care of the patient and the patient was
endorsed in good condition
(. Ass"re c!ntin"ity !$ care
> & good and complete endorsement$outgoing note guarantees continuity of care
for the patient It helps avoid repetitive database collection U mismanagement,
which can be very inconvenient and even irritating to the patient
c. ;acilitate trans$er !$ patient care
> & good endorsement$outgoing note provides an immediate insight on the entire
physical condition and program of the patient %his is best appreciated when the
patient has been undergoing P% for several months$years and$or has multiple
problems %he new therapist will be able to immediately care for the patient
without having to go through the entire chart -ust to find out what the case is,
what the most recent problems are, and what was the clinical course
%he endorsement$outgoing note, li+e any other P% document, is a formal document
It is improper to ma+e informal comments and even -o+es in the patient chart
> 8egative comments against the patient may reach them and they can always file
a formal complaint against the unit and the therapist (eg, .%ry to stretch your
patience with this patient Ge is so meticulous Ge always wants a new, good-
smelling bed sheet and towel["!
> If the patient has very valid special considerations, they should be written as
ob-ectively as possible (eg, .(a+e sure the patient"s P% schedule of D &( is
continued ,hange all linen prior to his treatment"!
> 5therwise, informal endorsements should be made on a separate piece of paper
and should be addressed only to the incoming therapist ,onfidentiality in such
matters should be observed at all times
*. Recei'in&<Inc!+in& N!tes
%he turnover notes of the incoming therapist
(ay be titled as .*eceiving 8ote" or .Incoming 8ote" depending on the facility
&re made only after the incoming therapist has reviewed the chart and performed a
re-evaluation (*1! of the patient
3hould contain a summary of the following:
a. Pertinent de+!&raphic data
(. S"++ary !$ the patient data(ase -S and O0 $!c"sin& !n pertinent $indin&s
c. Pr!(le+s identi$ied in the patient and their c"rrent stat"s
d. S"++ary !$ the clinical c!"rse !$ the patientCs case and the c!nditi!n "p!n
end!rse+ent
e. The physical e4a+inati!n $indin&s at the ti+e the ne) therapist $irst sa)
the patient
$. The treat+ent plan t! (e carried !"t (y the ne) therapist.
35&P format:
*eceiving 8ote
date
*eceived U treated today the case of (patient"s name!, a (age! y$o (sex! from
(address! who was referred for P%* due to ('x$P% Imp!
3: usually, only c$c: U summary of the GPI: (including the previous P% (x
*eceived! from the I1 up to the present treatment session are included here
5: usually included here are:
3ignificant 5: findings (eg, Q3, *5(, ((%! from the I1 U compared to a
pertinent re-evaluation performed on the present treatment session
P% (x *eceived: (complete with parameters, and including patient
education$instruction!
&: Problem )ist:
i. L -deter+ined as t! the pertinent re/e'al"ati!n per$!r+ed !n the present
treat+ent sessi!n.0
P: Planned P% (x: (complete with parameters, and including patient
education$instruction!
%. L
/requency of %x sessions: (schedule!
Precautions: (including special considerations!
3ignature
8ame
'esignation
8arrative format:
*eceiving 8ote
date
*eceived U treated today the case of (patient"s name!, a (age! y$o (sex! from
(address! who was referred for P%* due to ('x$P% Imp!
(c$c:!
(3ummary of GPI: including previous P% (x!
(3ummary of ob-ective findings from I1 compared to a pertinent re-evaluation
performed on the last treatment session upon endorsement!
,urrent Problem )ist:
%. L -state !nly pr!(le+s n!ted "p!n the present T4 sessi!n.0
P% (x *eceived: (complete with parameters, and including patient
education$instruction!
%. L
(/indings of pertinent re-evaluation performed on the present treatment session!
(Plans for further intervention and patient education$instruction!
(Precautions U special considerations!
3ignature
8ame
'esignation
8ote that many aspects of the receiving$incoming notes are in the
endorsement$outgoing notes
> %his has been ta+en advantage of by all health professionals, usually in a
negative way Qery often the outgoing notes are copied 6 sometimes even word-
for-word 8ever do this
& therapist should always arrive at his$her own receiving$incoming notes for the
following reasons:
a. Gi'e le&al pr!tecti!n t! the inc!+in& therapist
> In the event that the patient developed complications or problems before the
course of therapy to be implemented by the incoming therapist has commenced,
the incoming evaluation, which is performed prior to commencing intervention,
will confirm that such complication or problem was present prior to and did not
happen during the incoming therapist"s care of the patient and the patient may
not have been endorsed properly by the outgoing therapist, which ma+es the
previous therapist liable, or the condition or problem may have occurred in
between change in therapists %here is no guarantee that the outgoing therapist
gave a complete and honest endorsement and never assumes that he$she would
do so (even if the incoming therapist +nows the outgoing therapist personally!
(. Ne) chan&es c!"ld (e +issed
> 3ome time may have passed between the last re-evaluation of the patient and
the first time the incoming therapist sees the patient &ny new developments that
happened in between will therefore be absent in the endorsement notes
c. A pr!&ra+ +ay re>"ire i+pr!'e+ent<+!di$icati!n
> &n incoming therapist may want to modify the existing program of the patient
based on his$her re-evaluation Program improvement$modification can be
-ustified only if the incoming therapist thoroughly reviewed and studied the
patient"s case and clinical course
%he incoming therapist must confirm the endorsed findings and always perform
his$her own physical examination before implementing a treatment program %his information is
then summarized in the form of the receiving$incoming notes
D. Ter+inati!n N!tes
'ocumentation that are written upon the termination of an episode of care
,an be due to either discharge or discontinuation
%. Dischar&e S"++ary
%he last entry made by the therapist at the time the patient is discharged or decides
to discontinue P% services
3hould contain a summary of the following:
a. Pertinent de+!&raphic data
(. S"++ary !$ the patient data(ase -S and O0 $!c"sin& !n pertinent $indin&s
c. Pr!(le+s identi$ied in the patient
d. The c!rresp!ndin& treat+ent
e. S"++ary !$ the clinical c!"rse !$ the patientCs case speci$yin&:
i. The n"+(er !$ treat+ent sessi!ns and d"rati!n !$ the pr!&ra+
ii. A s"++ary !$ the pr!&ress !$ the patient
iii. Pertinent chan&es in the treat+ent
i'. O"tc!+e !$ the pr!&ra+
$. The dischar&e physical e4a+inati!n $indin&s -RE0
35&P format:
'ischarge 3ummary
date
'ischarged today the case of (Pt"s 8ame!, a (age! y$o (sex! from (address! who was
referred for P%* due to ('x$P% Imp!
3: usually, only c$c:, GPI:, and Gome 3ituation: from the I1 up to the date of
discharge, as well as whether the patient believes the goals set were achieved
and whether the patient feels ready to function at home are included here but
ultimately depends on the facility"s regulations
5: ultimately depends on the facility"s regulations, but usually included here are:
3ignificant 5: findings (eg, Q3, *5(, ((%! from the I1 U compared to a re-
evaluation performed on the date of discharge
&: Problem )ist:
%. L -deter+ined as t! the pr!(le+s identi$ied thr!"&h!"t the epis!de !$ care
and n!ted i$ they )ere res!l'ed !r still e4ist.0
)%#$1xpected /unctional 5utcomes:
%. L -list !nly the +!st recent LTGs and state i$ they )ere achie'ed !r n!t
achie'ed.0/ME+phasiAedN
3%#:
%. L -list !nly the +!st recent STGs and state i$ they )ere achie'ed !r n!t
achie'ed.0
P: P% (x *eceived: (complete with parameters U changes in intervention
throughout the episode of care, including any patient education$instruction!
%. L
,ompliance c P%:
%otal P% %x 3essions: (starting from the initial P% session up to the date of
discharge!
Precautions %a+en: (including special considerations!
*eason(s! for 'ischarge:
Plans for /urther Intervention$*eferral: (when necessary!
3ignature
8ame
'esignation
8arrative format:
'ischarge 3ummary
date
'ischarged today the case of (Pt"s 8ame!, a (age! y$o (sex! from (address! who was
referred for P%* due to ('x$P% Imp!
(c$c:!
(3ummary of GPI: up to date of discharge!
(Pertinent ob-ective findings from I1 up to date of discharge!
Problem )ist:
%. L
P% (x *eceived: (complete with parameters from I1 up to discharge including any
change in intervention and patient education$instruction!
%. L
(,ompliance c P%:!
(%otal %x 3essions starting from the initial P% session up to the last treatment
session!
(Progression of patient"s condition!
(/indings of re-evaluation performed on the date of discharge!
(Plans for further intervention$referral!
3ignature
8ame
'esignation
%wo (;! copies of the discharge summary should be made %hese are:
a. ;!r the !$$icial chart
(. ;!r the patient

APPENDICES
I. GUIDELINES ;OR PHFSICAL THERAPF DOCUBENTATION
)y the American Physical Therapy Association (APTA)
Prea+(le
%he &merican Physical %herapy &ssociation (&P%&! is committed to meeting the
physical therapy needs of society, to meeting the needs and interests of its members,
and to developing and improving the art and science of physical therapy, including
practice, education, and research %o help meet these responsibilities, the &P%& 9oard
of 'irectors has approved the following guidelines for physical therapy documentation It
is recognized that these guidelines do not reflect all of the unique documentation
requirements associated with the many specialty areas within the physical therapy
profession &pplicable for both handwritten and electronic documentation systems,
these guidelines are intended to be used as a foundation for the development of more
specific documentation guidelines in specialty areas, while at the same time providing
for the physical therapy profession across all practice settings
It is the position of &P%& that physical therapy examination, evaluation, diagnosis, and
prognosis shall be documented, dated, and authenticated by the physical therapist who
performs the service Intervention provided by the physical therapist or physical
therapist assistant is documented, dated, and authenticated by the physical therapist or,
when permissible by law, the physical therapist assistant, or both
5ther notations or flow charts are considered a component of the documented record
but do not meet the requirements of documentation in, or of, themselves (Position on
&uthority for Physical %herapy 'ocumentation, G5' ?B->D-==-==!
Operati!nal De$initi!ns
Guidelines: &P%& defines .guidelines" as approved, non-binding statements of advice
'ocumentation: &ny entry into the client record, such as consultation report, initial
examination report, progress note, flow sheet$chec+list that identifies the care$service
provided, reexamination, or summation of care
&uthentication: %he process used to verify that an entry is complete, accurate, and final
Indications of authentication can include original written signatures and computer
.signatures" on secured electronic record systems only
I. General G"idelines
& &ll documentation must comply with the applicable -urisdictional$regulatory
requirements
= &ll handwritten entries shall be made in in+ and will include original
signatures 1lectronic entries are made with appropriate security and
confidentiality provisions
; Informed consent: %he patient$client should be as+ed to ac+nowledge
understanding and consent before intervention is initiated
1xamples of ways in which to accomplish this documentation:
1x ;= 3ignature of patient$client or parent$legal guardian on long or
short consent form
1x ;; 8otation$entry of what was explained by the physical therapist in
the official record
1x ;C /iling of a completed consent chec+list signed by the
patient$client or parent$legal guardian
C ,harting errors should be corrected by drawing a single line through the error
and initialing and dating the chart or through the appropriate mechanism for
electronic documentation that clearly indicates that a change was made
without deletion of the original record
< Identification
<=Include patient"s$client"s full name and identification number, if applicable,
on all official documents
<;&ll entries must be dated and authenticated with the provider"s full name
and appropriate designation (ie, P% or P%&!
<C'ocumentation by graduates or others pending receipt of an unrestricted
license shall be authenticated by a licensed physical therapist
<<'ocumentation by students (3P%$3P%&! in physical therapist or physical
therapist assistant programs must be additionally authenticated by the
physical therapist or, when permissible by law, documentation by physical
therapist assistant students may be authenticated by a physical therapist
assistant
F 'ocumentation should include the referral mechanism by which physical
therapy services are initiated:
1xamples include:
1x F= 3elf-referral$direct access
1x F; *equest for consultation from a practitioner
II. Initial E4a+inati!n and E'al"ati!n<C!ns"ltati!n
& 'ocumentation is required at the onset of each episode of physical therapy care
9 'ocumentation of the initial episode of physical therapy care shall include the
following elements:
= 'ocumentation of appropriate history:
==Gistory of the presenting problem, current complaints, and precautions
(including onset date!
=;Pertinent diagnoses and medical history
=C'emographic characteristics, including pertinent psychosocial, social, and
environmental factors
=<Prior or concurrent services related to the current episode of physical
therapy care
=F,omorbidities that may affect the prognosis
=B3tatement of patient"s$client"s +nowledge of the problem
=E&nticipated goals of and expected outcomes for the patient$client (and
family members and significant others, if appropriate!
; 'ocumentation of a systems review
;='ocumentation of physiologic and anatomical status to include the
following systems:
;== ,ardiovascular$pulmonary
;=; Integumentary
;=C (usculos+eletal
;=< 8euromuscular
;;& review of communication, affect, cognition, language, and learning style
C 'ocumentation of selection and administration of appropriate tests and
measures to determine patient$client status in a number of areas and
documentation of findings %he following is a partial list of these areas to be
addressed in the documented examination and evaluation, including
illustrative tests and measures:
C=&rousal, attention, and cognition
1xamples include examination findings related, but not limited, to the
following areas:
1x C== )evel of consciousness
1x C=; &bility to process commands
1x C=C #ross expressive deficits
C;8euromotor development and sensory integration
1xamples include examination findings related, but not limited, to the
following areas:
1x C;= #ross and fine motor s+ills
1x C;; *eflex movement patterns
1x C;C 'exterity, agility, and coordination
CC*ange of motion
1xamples include examination findings related, but not limited, to the
following areas:
1x CC= 1xtent of -oint motion
1x CC; Pain and soreness of surrounding -oint tissue
1x CCC (uscle length and flexibility
C<(uscle performance (including strength, power, and endurance!
1xamples include examination findings related, but not limited, to the
following areas:
1x C<= /orce, velocity, torque, wor+, power
1x C<; (anual muscle test grades
1x C<C &mplitude, duration, waveform, and frequency of
electromyographic (1(#! signals
CFQentilation, respiration (gas exchange!, and circulation
1xamples include examination findings related, but not limited, to the
following areas:
1x CF= Geart rate (G*!, respiratory rate (**!, blood pressure (9P!
1x CF; &rterial blood gases
1x CFC Palpation of peripheral pulses
CBPosture
1xamples include examination findings related, but not limited, to the
following areas:
1x CB= 3tatic posture
1x CB; 'ynamic posture
CE#ait, locomotion, and balance
1xamples include examination findings related, but not limited, to the
following areas:
1x CE= ,haracteristics of gait
1x CE; /unctional locomotion
1x CEC ,haracteristics of balance
CD3elf-care and home management
1xamples include examination findings related, but not limited, to the
following areas:
1x CD= &ctivities of daily living
1x CD; /unctional capacity
1x CDC %ransfers
C>,ommunity and wor+ (-ob$school$play! integration or reintegration
1xamples include examination findings related, but not limited, to the
following areas:
1x C>= Instrumental activities of daily living
1x C>; /unctional capacity
1x C>C &daptive s+ills
< 'ocumentation of evaluation (a dynamic process in which the physical
therapist ma+es clinical -udgments based on data gathered during the
examination!
F 'ocumentation of diagnosis (a label encompassing a cluster of signs and
symptoms, syndromes, or categories that reflects the information obtained
from the examination!
B 'ocumentation of prognosis (determination of the level of optimal
improvement that might be attained through intervention and the amount of
time required to reach that level 'ocumentation shall include anticipated
goals, expected outcomes, and plan of care!
B=Patient$client (and family members and significant others, if appropriate! is
involved in establishing anticipated goals and expected outcomes
B;&ll anticipated goals and expected outcomes are stated in measurable
terms
BC&nticipated goals and expected outcomes are related to impairments,
functional limitations, and disabilities identified in the examination
B<&ll expected outcomes are stated in functional terms
BF%he plan of care:
BF= Is related to anticipated goals and expected outcomes
BF; Includes frequency and duration to achieve the anticipated goals
and expected outcomes
BFC Includes patient$client and family$caregiver educational goals
BF< Involves appropriate collaboration and coordination of care with
other professionals$services
E &uthentication by and appropriate designation of the physical therapist
III. D!c"+entati!n !$ the C!ntin"ati!n !$ Care
& 'ocumentation of intervention or services provided and current patient$client
status
= 'ocumentation is required for every visit$encounter
==&uthentication and appropriate designation of the physical therapist or the
physical therapist assistant providing the service under the direction and
supervision of a physical therapist
; 'ocumentation of each visit$encounter shall include the following 1lements:
;=Patient$client self-report (as applicable!
;;Identification of specific interventions provided, including frequency,
intensity, and duration as appropriate
1xamples include:
1x ;;= Tnee extension, C sets, =? repetitions, =?-lb weight
1x ;;; %ransfer training bed to chair with sliding board
;C1quipment provided
;<,hanges in patient$client status as they relate to the plan of care
;F&dverse reaction to interventions, if any
;B/actors that modify frequency or intensity of intervention and progression
toward anticipated goals, including patient$client adherence to
patient$client-related instructions
;E,ommunication$consultation with providers$patient$client$family$significant
other
9 'ocumentation of *eexamination
= 'ocumentation of reexamination is provided as appropriate to evaluate
progress and to modify or redirect intervention
; 'ocumentation of reexamination shall include the following elements:
;='ocumentation of elements as identified in III&; to update
patient"s$client"s status
;;Interpretation of findings and, when indicated, revision of anticipated goals
and expected outcomes
;C0hen indicated, revision of plan of care as directly correlated with
anticipated goals and expected outcomes as documented
;<&uthentication by and appropriate designation of the physical therapist
IG. D!c"+entati!n !$ S"++ati!n !$ Epis!de !$ Care
& 'ocumentation is required following conclusion of the current episode in the
physical therapy intervention sequence
9 'ocumentation of the summation of the episode of care shall include the
following elements:
= ,riteria for discharge
1xamples include:
1x == &nticipated goals and expected outcomes have been achieved
1x =; Patient$client, caregiver, or legal guardian declines to continue
intervention
1x =C Patient$client is unable to continue to wor+ toward anticipated
goals due to medical or psychosocial complications
1x =< Physical therapist determines that the patient$client will no
longer benefit from physical therapy
; ,urrent physical$functional status
C 'egree of anticipated goals and expected outcomes achieved and reasons
for goals and outcomes not being achieved
< 'ischarge plan that includes written and verbal communication related to the
patient"s$client"s continuing care
1xamples include:
1x <= Gome program
1x <; *eferrals for additional services
1x <C *ecommendations for follow-up physical therapy care
1x << /amily and caregiver training
1x <F 1quipment provided
F &uthentication by and appropriate designation of the physical therapist
Additi!nal Re$erences:
= Direction and "uper*ision of the Physical Therapist Assistant (G5' ?B->>-C?-<;!
; omprehensi*e Accreditation !anual for Hospitals 5a+broo+ terrace, Ill: Loint
,ommission on the &ccreditation of Gealthcare 5rganizations4 =>>B
C Glossary of Terms Related to +nformation "ecurity 3chaumburg, Ill: ,omputer-
based Patient *ecord Institute4 =>>B
< Guidelines for ,sta'lishin- +nformation security Policies at .r-ani/ations 0sin-
omputer1'ased Patient Records 3chaumburg, Ill: ,omputer-based Patient *ecord
Institute4 =>>F
F urrent Procedural Terminolo-y ,hicago: &merican (edical &ssociation (&(&!4
;???
B odin- and Payment Guide for the Physical Therapist 0ashington, ',: 3t
&nthony"s Publishing4 ;???
E !inimal Data "et (!D") Re-ulations Gealthcare /inancing &dministration (G,/&!
&vailable at: wwwhcfagov
D 22A$A!A Documentation Guidelines Gealthcare /inancing &dministration (G,/&!
&vailable at: wwwhcfagov
> Gome Gealth *egulations Gealthcare /inancing &dministration (G,/&! &vailable
at: wwwhcfagov
=? "tate Practice Acts &vailable at: wwwfsbptorg
&dopted by the 9oard of 'irectors, &P%&, (arch =>>C
&mended (arch ;???, 8ovember =>>D, (arch =>>E, (arch =>>F, 8ovember =>><,
Lune =>>C, (arch =>>C
&P%& documents are revised on a regular basis /or the most recent revisions, contact
wwwaptaorg or &P%&"s 3ervice ,enter at D??$C>>-;ED;, ext CC>F
II. SABPLE GENERIC PHFSICAL THERAPF PATIENT EGALUATION ;ORB
PERSONAL DATA :
8ame : ,
&ge :
&ddress :
%el 8o :
3ex : ( ! ( ( ! /
9irthdate :
8ationality :
,ivil 3tatus : ( ! 3 ( ! ( ( ! 0
5ccupation :
*eligion :
Gandedness : ( ! * ( ! ) ( ! 9
*oom \ :
*eferring (' :
'ate of *eferral :
Physiatrist :
'ate of ,onsultation :
'x :
(edications :
%ype of 1val : ( ! I1 ( ! *1
'ate of 1val :
P% Imp :
S :
,$, :
GPI :
P(G :
G/' :
P t (aternal Paternal
GP8
*&
,&
'(
&sthma
,ardiac dss
/'& :
Gome 3ituation :
Pt"s )ifestyle :
3mo+ing Gx :
'rin+ing Gx :
'rug Gx :
'aily &ctivities :
0or+ &ctivities :
*ecreational &ctivities :
3tatus P%, :
Pt"s #oal :
O :
I83P1,%I58 :
5verall Impression :
(ental &lertness : 5rientation : ,onsciousness : ( ! conscious
( ! alert ( ! person ( ! unconscious
( ! lethargic ( ! place ,oherence : ( ! coherent
( ! obtunded ( ! time ( ! incoherent
( ! stuporous ,ooperation : ( ! cooperative
( ! semi-comatose ( ! uncooperative
( ! comatose
#eneral &ppearance :
(ethod of %ransport :
Physique :
3+in &ppearance :
Posture :
&ttachments :
'eformity :
5thers :

,ommunication 3+ills:
( ! #ood /or /air U Poor :
( ! /air *eason :
( ! Poor /orm of ,ommunication :( ! verbal ( ! gestures ( ! written
,&*'I5Q&3,2)&*$P2)(58&*N &33133(18% :
Qital 3igns :
] % x 'uring %x p % x method$location$position
9P : (mmGg!
P* : (bpm!
** : (cpm!
3ig :
,1( :
*elaxed 1xpiration (aximal Inspiration ' i f f
)evel of &xilla (cm!
Wiphoid Process (cm!
% = ? ( c m !
3ig:
&uscultation :
9reath 3ounds :
Geart 3ounds :
Peripheral Pulses :
P&)P&%I58 :
(uscle %one :
3+in %emperature :
3+in %exture:
3+in %urgor :
3+in ,onsistency :
3+in (obility :
%ender &reas :
5thers :
812*5)5#I, &33133(18% :
3ensation :
3%'"s used:
*eflexes :
(3* $ '%* : (*! ()! )egend : ? Yareflexia
M Yhyporeflexia
MM Ynormoreflexia
MMM Yhyperreflexia
MMMM Yclonus

3ig:
3uperficial *eflexes :
Pathologic *eflexes :
,ranial 8erve &ssessment :
(23,2)53T1)1%&) &33133(18% :
Loint Play :
*5( :
((% :
(9% :
)#( :
))' :
(*! ()! 'iff 3ig
%rue )eg )ength
&pparent )eg )ength
3ig:
P53%2*&) &33133(18% :
#&I% &33133(18% :
/28,%I58&) &33133(18% :
/I( :
9alance :
3itting : 3tanding : 0al+ing:
%olerance :
3itting : 3tanding : 0al+ing:
3P1,I&) %13%3 :
8ame of %est *esults 3ignificance
#eneral 3ignificance :
A :
'x :
P% Imp :
Problem )ist :

)%# :
3%# :
P :
P% (x to be received : /requency : %otal 3essions :
Gome Instructions$Gome 1xercise Program :
Pt$/amily 1ducation :
Precautions :
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
III. SABPLE PEDIATRIC EGALUATION ;ORB
General In$!r+ati!n
'ate of 1valuation:
8ame:
&ge:
3ex:
&ddress:
9irthdate:
'iagnosis:
&ttending Physician:
*eferred by:
(edications %a+en:
P% Impression:
S"(=ecti'e:
(aternal Gistory:
/amilial 'isease:
3mo+er:
'rin+er:
'elivery U 5bstetrical 3core:
Prenatal:
&ge:
Prenatal ,are:
(edication:
%rauma$&ccident:
&ttitude toward Pregnancy:
Perinatal:
0ee+s: #estation:
8ature of 'elivery:
Presentation:
Place of 'elivery:
9irth 0eight:
&P#&* 3core:
,riteria ? = ;
&ppearance 9lue$ ,yanotic4 Pale 9ody Pin+4 1xtremity 9lue &ll Pin+
Pulse 8egative _ =?? Z =??
#rimace 8egative #rimace ,ough4 3neeze
&ctivity )imp 3ome /lexion &ctivities &ctive (otion
*espiration 8egative 3low Irregular #ood ,rying
If score is:
_ E resuscitation is required
Z E needs simple measures such as clearing the airway, U administering oxygen may evo+e an adequate
response
8ormal between F U E
Postnatal:
%rauma$Illness:
(edication:
&ncillary Procedures (date U result!:
Immunization:
Previous$,urrent %herapy:
8utritional Gistory:
9reast /eeding (duration!:
(il+ (dilution if correct!:
3olid food (when!, diet:
/eeding Problems:
,urrent &ppetite:
Psychological 1valuation:
*an+ of Patient:
8o of 3iblings:
Primary ,aregiver:
1ducational level: /ather: (other:
5ccupation: /ather: (other:
&ttitudes towards disability:
,hief ,omplaint $ #oals for the ,hild:
O(=ecti'e:
5cular Inspection:
(ode of &mbulation: 9races:
9ehavior: Involuntary (ovement:
Posture: 3hunt:
Postural 'eformity: 3+in:
Gead 3ize, 3hape: 'rooling:
1ye 'eformity: 9ody 9uilt:
,oncentration 3pan: ,ommunication 3+ill:
#rade: P unable to return to tas+ even with prompting
/ able to return to tas+ with prompting
# not distracted
(ental &lertness:
Palpation:
%one &ssessment (%run+ U 1xtremities!
*ight )eft
%run+
21
)1
#rading: ? 8o increase in muscle tone
= (in resistance at end of *5(
=M (in resistance _=$; of *5(
; (ar+ed resistance through most of *5(
C Passive movement difficult4 considerable increase in tone
< &ffected parts rigid in flexion or extension
3ensory &ssessment:
()ight touch, Pin Pric+, 'eep Pressure, Proprioception, Tinesthesia, U 3%' used!
Qisual )ocalization: %rac+ing: %hreat:
&uditory )ocalization: %rac+ing:
*ange 5f (otion:
* ) * ) * ) * ) * ) * ) * )
08)
Gypermobile
,ontracture
Loint 0ith )5(
Loint:
(otion 8ormal *5( &vailable *5(
&ccessory Loint (otion:
Loint (otion #rade
#rading: ? an+ylosis
= considerable hypomobility
; slight hypomobility
C normal
< slight hypermobility
F considerable hypermobility
B unstable
(anual (uscle %esting:
(uscle 9ul+ %est:
'eep %endon *eflexes: (*! ()! )egend : ? Yareflexia
M Yhyporeflexia
MM Ynormoreflexia
MMM Yhyperreflexia
MMMM Yclonus
'evelopmental *eflexes:
3PI8&) *1/)1W13
/lexor 0ithdrawal
1xtensor %hrust
%raction
(oro
3tartle
#rasp
9*&I83%1( *1/)1W13
&%8*
3%8*
)abyrinthine *ighting
Positive 3upporting
&ssociated *eactions
(I'9*&I8 *1/)1W13
8ec+ *ighting
9ody *ighting
)abyrinthine Gead *ighting
5ptical *ighting
1P2I)I9*I2( *1&,%I58
3upine
Prone
Puadruped
3itting
Tneeling
3tanding
P*5%1,%IQ1 1W%183I58
/ront
3ideways to )eft
3ideways to *ight
9ac+
'evelopmental 3+ills
G1&' ,58%*5) #*&'1 '1%&I)3
o Pull %o 3it
o Prone
o 3itting
o 3tanding
%*28T ,58%*5)
o *olling 5ver
o Prone 5n 1lbows
o 3itting
o 3tanding
P1)QI, ,58%*5)
o Pelvic 9ridging
o Puadruped
o Tneeling
o 3tanding
)egend: = no ability
; beginning ability with difficulty
C achieve with abnormal pattern
< near normal
9alance $ %olerance:
9alance 'etails %olerance 'etails
3itting
Tneeling
3tanding
0al+ing
9alance #rade: 8 Pt is able to maintain balance without support &ccepts max challenge U can
shift weight In all directions
# Pt is able to maintain balance without support &ccepts mod challenge U can
shift weight &lthough limitations are evident
/ Pt is able to maintain balance without support ,annot tolerate challenge ,ant
maintain 9alance while shifting weight
P Pt requires support to maintain balance
? Pt requires max assistance to maintain balance
%olerance #rade: P (-! _ =F min
P =F-C? min
/ (-! C?-<F min
/ <F-B? min
# Z= hr
,oordination &ssessment:
*ating 3cale: < 8ormal performance is demonstrated
C (ovement is accomplished with only slight difficulty
; (oderate difficulty is demonstrated in accomplishing activity4 movements are
arrhythmic, U performance deteriorates with increase speed
= 3evere difficulty is noted4 movement are very arrhythmic4 significant
unsteadiness, 5scillations, U$or extraneous movements are noted
? Patient is unable to accomplish activity
8on-1quilibrium ,oordination %est 1quilibrium ,oordination %est
7&t least F tests 7&t least F tests
(59I)I%N$ &(92)&%I58 ,G1,T '1%&I)3
'ependent$ &ssisted
,reeping
,rawling
Tneel 0al+ing
0al+ing
5thers 3pecify:
%*&83/1*3 ,G1,T '1%&I)3
'ependent
&ssisted
Independent
P53%2*&) &8&)N3I3:
3itting U 3tanding Position
&8%1*I5* QI10 P53%1*I5* QI10 )&%1*&) QI10
Gead
/oot
#&I% &8&)N3I3:
GIP T811 &8T)1
G3-//
//-(3
(3-G5
G5-%5
&cceleration
(idswing
'eceleration
&'):
/eeding
9athing
Personal %oilet (9rushing %eeth, Gair, 0ashing /ace!
'ressing
9owel
9ladder
ASSESSBENT:
P% I(P*133I58:
P*59)1( )I3%:
)%#:
3%#:
PLAN:
G5(1 1W1*,I31 P*5#*&(:
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
IG. Physical Therapy Tests and Beas"res
Accordin- to APTAs Guide to Physical Therapist Practice
A. Intr!d"cti!n
%he following are the categories of tests and measures used in physical therapy
*egardless of the specific test or measure used on a patient$client, the results of
any of these tests$measures are integrated with:
%. The hist!ry and syste+s re'ie) $indin&s. and
*. The res"lts !$ !ther tests and +eas"res
&ll of these data are then synthesized during the evaluation process to establish:
%. The dia&n!sis
*. The pr!&n!sis. and
1. The plan !$ care. )hich incl"des the selecti!n !$ inter'enti!ns.
%he results of these tests and measures may indicate:
%. The need t! "se !r rec!++end !ther tests and +eas"res. !r
*. The need t! c!ns"lt )ith. !r re$er the patient<client t!. an!ther pr!$essi!nal.
,linical indications for the use of tests and measures are predicated on the
history and systems review findings, meaning:
%. In$!r+ati!n pr!'ided (y the patient<client. $a+ily. si&ni$icant !ther. !r care&i'er
*. Sy+pt!+s descri(ed (y the patient<client
1. Si&ns !(ser'ed and d!c"+ented d"rin& the syste+s re'ie). and
2. In$!r+ati!n deri'ed $r!+ !ther s!"rces !r rec!rds.
%he findings may indicate the presence of or ris+ for pathology$pathophysiology
(disease, disorder, or condition!, impairments, functional limitations, or disabilities
that require a more definitive examination through the selection of an appropriate
test or measure
,. Cate&!ries !$ Physical Therapy Tests and Beas"res
%. Aer!(ic Capacity<End"rance
&erobic capacity$endurance
> Is the ability to perform wor+ or participate in activity over time using the body"s
oxygen upta+e, delivery, and energy release mechanisms
'uring activity, the physical therapist uses tests and measures ranging from simple
measurements to complex calculations to determine the appropriateness of patient$client
responses to increased oxygen demand
*esponses that are monitored both at rest and during and after activity may indicate
the degree of severity of the impairment, functional limitation, or disability
%ests and measures may include those that characterize or quantify:
a. Aer!(ic capacity d"rin& $"ncti!nal acti'ities
> &ctivities of daily living (&')! scales
> Indexes
> Instrumental activities of daily living (I&')! scales
> 5bservations
(. Aer!(ic capacity d"rin& standardiAed e4ercise test pr!t!c!ls
> 1rgometry
> 3tep tests
> %ime$distance wal+$run tests
> %readmill tests
> 0heelchair tests
c. Cardi!'asc"lar si&ns and sy+pt!+s in resp!nse t! increased !4y&en
de+and )ith e4ercise !r acti'ity. incl"din& press"res and $l!)? heart rate.
rhyth+. and s!"nds? and s"per$icial 'asc"lar resp!nses
> &ngina, claudication, dyspnea, and exertion scales
> 1lectrocardiography
> 5bservations
> Palpation
> 3phygmomanometry
d. P"l+!nary si&ns and sy+pt!+s in resp!nse t! increased !4y&en de+and
)ith e4ercise !r acti'ity. incl"din& (reath and '!ice s!"nds? cyan!sis? &as
e4chan&e? respirat!ry pattern. rate. and rhyth+? and 'entilat!ry $l!). $!rce.
and '!l"+e
> &uscultation
> 'yspnea and exertion scales
> #as analyses
> 5bservations
> 5ximetry
> Palpation
> Pulmonary function tests
%ools for gathering data may include:
a. De'ices $!r &as analysis
(. Electr!cardi!&raphs
c. Er&!+eters
d. ;!rce +eters
e. Inde4es
$. Beas"red )al3)ays
&. N!+!&ra+s
h. O(ser'ati!ns
i. Palpati!n
=. P"lse !4i+eters
3. Scales
l. Sphy&+!+an!+eters
+. Spir!+eters
n. Steps
!. Steth!sc!pes
p. St!p )atches
>. Tread+ills
'ata generated are used in providing documentation and may include:
a. Cardi!'asc"lar and p"l+!nary si&ns. sy+pt!+s. and resp!nses per "nit !$
)!r3
(. Gas '!l"+e. c!ncentrati!n. and $l!) per "nit !$ )!r3
c. Heart rate. rhyth+. and s!"nds per "nit !$ )!r3
d. O4y&en "pta3e d"rin& $"ncti!nal acti'ity
e. O4y&en "pta3e. ti+e and distance )al3ed !r (icycled. and +a4i+"+
aer!(ic per$!r+ance
$. Peripheral 'asc"lar resp!nses per "nit !$ )!r3
&. Respirat!ry rate. rhyth+. pattern. and (reath s!"nds per "nit !$ )!r3
*. Anthr!p!+etric Characteristics
&nthropometric characteristics
> &re those traits that describe body dimensions, such as height, weight, girth, and
body fat composition
%he physical therapist uses tests and measures to quantify these traits
%ests and measures may include those that characterize or quantify:
a. ,!dy c!+p!siti!n
> 9ody mass index
> Impedance measurement
> 3+in-fold thic+ness measurement
(. ,!dy di+ensi!ns
> 9ody mass index
> #irth measurement
> )ength measurement
c. Ede+a
> #irth measurement
> Palpation
> 3cales
> Qolume measurement
%ools for gathering data may include:
a. ,!dy +ass inde4
(. Calipers
c. Ca+eras and ph!t!&raphs
d. I+pedance de'ices
e. N!+!&ra+s
$. Palpati!n
&. R"lers
h. Scales
i. Tape +eas"res
=. G!l"+eters
3. ei&ht scales
'ata generated are used in providing documentation and may include:
a. Hei&ht and )ei&ht
(. Presence and se'erity !$ a(n!r+al (!dy $l"id distri("ti!n
1. Ar!"sal. Attenti!n. and C!&niti!n
&rousal
> Is a state of responsiveness to stimulation or action or of physiological readiness
for activity
&ttention
> Is the selective awareness of the environment or selective responses to stimuli
,ognition
> Is the act or process of +nowing, including both awareness and -udgment
%he physical therapist uses tests and measures to characterize the patient"s$client"s
responsiveness
%ests and measures may include those that characterize or quantify:
a. Ar!"sal and attenti!n
> &daptability tests
> &rousal and awareness scales
> Indexes
> Profiles
> Puestionnaires
(. C!&niti!n. incl"din& a(ility t! pr!cess c!++ands
> 'evelopmental inventories
> Indexes
> Interviews
> (ental state scales
> 5bservations
> Puestionnaires
> 3afety chec+lists
c. C!++"nicati!n
> /unctional communication profiles
> Interviews
> Inventories
> 5bservations
> Puestionnaires
d. C!nsci!"sness. incl"din& a&itati!n and c!+a
> 3cales
e. B!ti'ati!n
> &daptive behavior scales
$. Orientati!n t! ti+e. pers!n. place. and sit"ati!n
> &ttention tests
> )earning profiles
> (ental state scales
&. Recall. incl"din& +e+!ry and retenti!n
> &ssessment scales
> Interviews
> Puestionnaires
%ools for gathering data may include:
a. Adapta(ility tests
(. Attenti!n tests
c. Inde4es
d. Inter'ie)s
e. In'ent!ries
$. O(ser'ati!ns
&. Pr!$iles
h. #"esti!nnaires
i. Sa$ety chec3lists
=. Scales
3. Screenin& tests
'ata generated are used in providing documentation and may include:
a. Descripti!ns !$ sh!rt/ter+ and l!n&/ter+ +e+!ry
(. Presence and se'erity !$:
> ,ognitive impairment
> ,oma
> ,ommunication deficits
> 'epression or impaired motivation
> Impaired consciousness
c. #"anti$icati!n !r characteriAati!n !$:
> &bility to attend to tas+ or to participate
> &bility to recognize time, person, place, and situation
2. Assisti'e and Adapti'e De'ices
&ssistive and adaptive devices
> &re implements and equipment used to aid patients$clients in performing tas+s
and movements
&ssistive devices include:
> ,rutches
> ,anes
> 0al+ers
> 0heelchairs
> Power devices
> )ong-handled reachers
> Percussors
> 3tatic and dynamic splints
> Qibrators
&daptive devices include:
> *aised toilet seats
> 3eating systems
> 1nvironmental controls
%he physical therapist uses tests and measures to determine whether a patient$client
might benefit from such a device or, when such a device is already in use, to assess how well
the patient$client performs with it
%ests and measures may include those that characterize or quantify:
a. Assisti'e !r adapti'e de'ices and e>"ip+ent "se d"rin& $"ncti!nal
acti'ities
> &ctivities of daily living (&')!
> /unctional scales
> Instrumental activities of daily living (I&')! scales
> Interviews
> 5bservations
(. C!+p!nents. ali&n+ent. $it. and a(ility t! care $!r the assisti'e !r adapti'e
de'ices and e>"ip+ent
> Interviews
> )ogs
> 5bservations
> Pressure-sensing maps
> *eports
c. Re+ediati!n !$ i+pair+ents. $"ncti!nal li+itati!ns. !r disa(ilities )ith "se
!$ assisti'e !r adapti'e de'ices and e>"ip+ent
> &ctivity status indexes
> &') scales
> &erobic capacity tests
> /unctional performance inventories
> Gealth assessment questionnaires
> I&') scales
> Pain scales
> Play scales
> Qideographic assessments
d. Sa$ety d"rin& "se !$ assisti'e !r adapti'e de'ices and e>"ip+ent
> 'iaries
> /all scales
> Interviews
> )ogs
> 5bservations
> *eports
%ools for gathering data may include:
a. Acti'ity stat"s inde4es
(. Aer!(ic capacity tests
c. Diaries
d. ;"ncti!nal per$!r+ance instr"+ents
e. Health assess+ent >"esti!nnaires
$. Inter'ie)s
&. L!&s
h. O(ser'ati!ns
i. Press"re/sensin& de'ices
=. Rep!rts
3. Scales
l. Gide! ca+eras and 'ide!tapes
'ata generated are used in providing documentation and may include:
a. Descripti!ns !$:
> &lignment and fit of devices and equipment
> &bility to use and care for devices and equipment
> ,omponents of assistive and adaptive devices and equipment
> )evel of safety with devices and equipment
> Practicality of devices and equipment
> *emediation of impairment, functional limitation, or disability with devices and
equipment
(. #"anti$icati!ns !$:
> (ovement patterns with or without devices and equipment
> Physiological and functional effect and benefit of devices and equipment
5. Circ"lati!n -Arterial. Gen!"s. Ly+phatic0
,irculation
> Is the movement of blood through organs and tissues to deliver oxygen and to
remove carbon dioxide and the passive movement (drainage! of lymph through
channels, organs, and tissues for removal of cellular byproducts and
inflammatory wastes
%he physical therapist uses the results of circulation tests and measures to
determine whether the patient$client has adequate cardiovascular pump, circulation, oxygen
delivery, and lymphatic drainage systems to meet the body"s demands at rest and with activity
%ests and measures may include those that characterize or quantify:
a. Cardi!'asc"lar si&ns. incl"din& heart rate. rhyth+. and s!"nds? press"res
and $l!)? and s"per$icial 'asc"lar resp!nses
> &uscultation
> ,laudication scales
> 1lectrocardiography
> #irth measurement
> 5bservations
> Palpation
> 3phygmomanometry
> %hermography
(. Cardi!'asc"lar sy+pt!+s
> &ngina
> ,laudication
> 'yspnea
> Perceived exertion scales
c. Physi!l!&ical resp!nses t! p!siti!n chan&e. incl"din& a"t!n!+ic
resp!nses. central and peripheral press"res. heart rate and rhyth+.
respirat!ry rate and rhyth+. 'entilat!ry pattern
> &uscultation
> 1lectrocardiography
> 5bservations
> Palpation
> 3phygmomanometry
%ools for gathering data may include:
a. D!ppler "ltras!n!&raphs
(. Electr!cardi!&raphs
c. O(ser'ati!ns
d. Palpati!n
e. Scales
$. Sphy&+!+an!+eters
&. Steth!sc!pes
h. Tape +eas"res
i. Ther+!&raphs
=. Tilt ta(les
'ata generated are used in providing documentation and may include:
a. Characteristics !$:
> ,entral pressure and volume
> Intracranial pressure responses
> Physiological responses to position change
(. Descripti!ns !$:
> Peripheral arterial circulation
> Peripheral lymphatic circulation
> Peripheral venous circulation
> 3+in color
> 8ail changes
c. Presence !$ (r"its
d. Presence and se'erity !$:
> &bnormal heart sounds
> &bnormal heart rate or rhythm at rest
> ,ardiovascular signs and symptoms
> 1dema
e. #"anti$icati!ns !$ cardi!'asc"lar p"+p de+and
$. Gital si&ns at rest
6. Cranial and Peripheral Ner'e Inte&rity
,ranial nerve integrity
> Is the intactness of the twelve (=;! pairs of nerves connected with the brain,
including their somatic, visceral, and afferent and efferent components
Peripheral nerve integrity
> Is the intactness of the spinal nerves, including their afferent and efferent
components
%he physical therapist uses tests and measures to assess the cranial and peripheral
nerves
%ests and measures may include those that characterize or quantify:
a. Electr!physi!l!&ical inte&rity
> 1lectroneuromyography
(. B!t!r distri("ti!n !$ the cranial ner'es
> 'ynamometry
> (uscle tests
> 5bservations
c. B!t!r distri("ti!n !$ the peripheral ner'es
> 'ynamometry
> (uscle tests
> 5bservations
> %horacic outlet tests
d. Resp!nse t! ne"ral pr!'!cati!n
> %ension tests
> Qertebral artery compression tests
e. Resp!nse t! sti+"li. incl"din& a"dit!ry. &"stat!ry. !l$act!ry. pharyn&eal.
'esti("lar. and 'is"al
> 5bservations
> Provocation tests
$. Sens!ry distri("ti!n !$ the cranial ner'es
> 'iscrimination tests
> %actile tests, including coarse and light touch, cold and heat, pain, pressure, and
vibration
&. Sens!ry distri("ti!n !$ the peripheral ner'es
> 'iscrimination tests
> %actile tests, including coarse and light touch, cold and heat, pain, pressure, and
vibration
> %horacic outlet tests
%ools for gathering data may include:
a. Dyna+!+eters
(. Electr!ne"r!+y!&raphs
c. B"scle tests
d. O(ser'ati!ns
e. Palpati!n
$. Pr!'!cati!n tests
&. Scales
h. Sens!ry tests
'ata generated are used in providing documentation and may include:
a. Descripti!ns and >"anti$icati!n !$:
> 3ensory responses to provocation of cranial and peripheral nerves
> Qestibular responses
(. Descripti!ns !$ a(ility t! s)all!)
c. Presence !r a(sence !$ &a& re$le4
d. #"anti$icati!ns !$ electr!physi!l!&ical resp!nse t! sti+"lati!n
e. Resp!nse t! ne"ral pr!'!cati!n
7. En'ir!n+ental. H!+e. and !r3 -E!(<Sch!!l<Play0 ,arriers
1nvironmental, home, and wor+ (-ob$school$play! barriers
> &re the physical impediments that +eep patients$clients from functioning optimally
in their surroundings
%he physical therapist uses the results of tests and measures to identify any of a
variety of possible impediments, including:
a. Sa$ety haAards
> %hrow rugs
> 3lippery surfaces
(. Access pr!(le+s
> 8arrow doors
> %hresholds
> Gigh steps
> &bsence of power doors or elevators
c. H!+e !r !$$ice desi&n (arriers
> 1xcessive distances to negotiate
> (ultistory environments
> 3in+s
> 9athrooms
> ,ounters
> Placement of controls or switches
%he physical therapist also uses the results to suggest modifications to the
environment that will allow the patient$client to improve functioning in the home, wor+place, and
other settings, such as:
> #rab bars in the showers
> *amps
> *aised toilet seats
> Increased lighting
%ests and measures may include those that characterize or quantify:
a. C"rrent and p!tential (arriers
> ,hec+lists
> Interviews
> 5bservations
> Puestionnaires
(. Physical space and en'ir!n+ent
> ,ompliance standards
> 5bservations
> Photographic assessments
> Puestionnaires
> 3tructural specifications
> %echnology-assisted assessments
> Qideographic assessments
%ools for gathering data may include:
a. Ca+eras and ph!t!&raphs
(. Chec3lists
c. Inter'ie)s
d. O(ser'ati!ns
e. #"esti!nnaires
$. Str"ct"ral speci$icati!ns
&. Techn!l!&y/assisted analysis syste+s
h. Gide! ca+eras and 'ide!tapes
'ata generated are used in providing documentation and may include:
a. Descripti!ns !$:
> 9arriers
> 1nvironment
(. D!c"+entati!n and descripti!n !$ c!+pliance )ith re&"lat!ry standards
c. O(ser'ati!ns !$ en'ir!n+ent
d. #"anti$icati!ns !$ physical space
8. Er&!n!+ics and ,!dy Bechanics
1rgonomics
> Is the relationship among the wor+er4 the wor+ that is done4 the actions, tas+s or
activities inherent in that wor+ (-ob$school$play!4 and the environment in which the
wor+ (-ob$school$play! is performed
> 2ses scientific and engineering principles to improve safety, efficiency, and
quality of movement involved in wor+ (-ob$school$play!
9ody mechanics
> &re the interrelationships of the muscles and -oints as they maintain or ad-ust
posture in response to forces placed on or generated by the body
%he physical therapist uses these tests and measures in examining both the wor+er
and the wor+ (-ob$school$play! environment and in determining the potential for trauma or
repetitive stress in-uries from inappropriate wor+place design
> %hese tests and measures may be conducted after a wor+ in-ury or as a
preventive step
%he physical therapist may conduct tests and measures as part of wor+ hardening or
wor+ conditioning programs and may use the results of tests and measures to develop such
programs
1rgonomics tests and measures may include those that characterize or quantify:
a. De4terity and c!!rdinati!n d"rin& )!r3 -=!(<sch!!l<play0
> Gand function tests
> Impairment rating scales
> (anipulative ability tests
(. ;"ncti!nal capacity and per$!r+ance d"rin& )!r3 acti!ns. tas3s. !r
acti'ities
> &ccelerometry
> 'ynamometry
> 1lectroneuromyography
> 1ndurance tests
> /orce platform tests
> #oniometry
> Interviews
> 5bservations
> Photographic assessments
> Physical capacity tests
> Postural loading analyses
> %echnology-assisted assessments
> Qideographic assessments
> 0or+ analyses
c. Sa$ety in )!r3 en'ir!n+ents
> Gazard identification chec+lists
> Lob severity indexes
> )ifting standards
> *is+ assessment scales
> 3tandards for exposure limits
d. Speci$ic )!r3 c!nditi!ns !r acti'ities
> Gandling chec+lists
> Lob simulations
> )ifting models
> Pre-employment screenings
> %as+ analysis chec+lists
> 0or+station chec+lists
e. T!!ls. de'ices. e>"ip+ent. and )!r3stati!ns related t! )!r3 acti!ns. tas3s.
!r acti'ities
> 5bservations
> %ool analysis chec+lists
> Qibration assessments
9ody mechanics tests and measures may include those that characterize or quantify:
a. ,!dy +echanics d"rin& sel$/care. h!+e +ana&e+ent. )!r3. c!++"nity. !r
leis"re acti!ns. tas3s. !r acti'ities
> &ctivities of daily living (&')! and instrumental activities of daily living (I&')!
scales
> 5bservations
> Photographic assessments
> %echnology-assisted assessments
> Qideographic assessments
%ools for gathering data may include:
a. Acceler!+eters
(. Ca+eras and ph!t!&raphs
c. Chec3lists $!r e4p!s"re standards. haAards. li$tin& standards
d. Dyna+!+eters
e. Electr!ne"r!+y!&raphs
$. En'ir!n+ental tests
&. ;!rce plat$!r+s
h. ;"ncti!nal capacity e'al"ati!ns
i. G!ni!+eters
=. Hand $"ncti!n tests
3. Inde4es
l. Inter'ie)s
+. B"scle tests
n. O(ser'ati!ns
!. Physical capacity and end"rance tests
p. #"esti!nnaires
>. Scales
r. Screenin&s
s. Techn!l!&y/assisted analysis syste+s
t. Gide! ca+eras and 'ide!tapes
". !r3 analyses
/or ergonomics, data generated are used in providing documentation and may
include:
a. CharacteriAati!ns !$ e$$iciency and e$$ecti'eness !$ "se !$ t!!ls. de'ices.
and )!r3stati!ns
(. CharacteriAati!ns !$ en'ir!n+ental haAards. health ris3s. and sa$ety ris3s
c. Descripti!ns !$ t!!ls. de'ices. e>"ip+ent. and )!r3stati!ns
d. Descripti!ns and >"anti$icati!n !$:
> &bnormal movement patterns associated with wor+ actions, tas+s, or activities
> 'exterity and coordination
> /unctional capacity
> *epetition and wor+$rest cycle in wor+ actions, tas+s, or activities
> 0or+ actions, tas+s, or activities
e. Presence !r a(sence !$ act"al. p!tential. !r repetiti'e tra"+a in the )!r3
en'ir!n+ent
/or body mechanics, data generated are used in providing documentation on body
mechanics and may include:
a. CharacteriAati!ns !$ a(n!r+al !r "nsa$e (!dy +echanics
(. Descripti!ns and >"anti$icati!n !$ li+itati!ns in sel$/care. h!+e
+ana&e+ent. )!r3. c!++"nity. and leis"re acti!ns. tas3s. !r acti'ities
9. Gait. L!c!+!ti!n. and ,alance
#ait
> Is the manner in which a person wal+s, characterized by rhythm, cadence, step,
stride, and speed
)ocomotion
> Is the ability to move from one place to another
9alance
> Is the ability to maintain the body in equilibrium with gravity both statically (ie,
while stationary! and dynamically (ie, while moving!
%he physical therapist uses these tests and measures to assess disturbances in gait,
locomotion, and balance and assess the ris+ for falling
%he physical therapist also uses these tests and measures to determine whether the
patient$client is a candidate for assistive, adaptive, orthotic, protective, supportive, or prosthetic
devices or equipment
#ait, locomotion, and balance problems often involve difficulty in integrating sensory,
motor, and neural processes
%ests and measures may include those that characterize or quantify:
a. ,alance d"rin& $"ncti!nal acti'ities )ith !r )ith!"t the "se !$ assisti'e.
adapti'e. !rth!tic. pr!tecti'e. s"pp!rti'e. !r pr!sthetic de'ices !r
e>"ip+ent
> &ctivities of daily living (&')! scales
> Instrumental activities of daily living (I&')! scales
> 5bservations
> Qideographic assessments
(. ,alance -dyna+ic !r static0 )ith !r )ith!"t the "se !$ assisti'e. adapti'e.
!rth!tic. pr!tecti'e. s"pp!rti'e. !r pr!sthetic de'ices !r e>"ip+ent
> 9alance scales
> 'izziness inventories
> 'ynamic posturography
> /all scales
> (otor impairment tests
> 5bservations
> Photographic assessments
> Postural control tests
c. Gait and l!c!+!ti!n d"rin& $"ncti!nal acti'ities )ith !r )ith!"t the "se !$
assisti'e. adapti'e. !rth!tic. pr!tecti'e. s"pp!rti'e. !r pr!sthetic de'ices
!r e>"ip+ent
> &') scales
> #ait indexes
> I&') scales
> (obility s+ill profiles
> 5bservations
> Qideographic assessments
d. Gait and l!c!+!ti!n )ith !r )ith!"t the "se !$ assisti'e. adapti'e. !rth!tic.
pr!tecti'e. s"pp!rti'e. !r pr!sthetic de'ices !r e>"ip+ent
> 'ynamometry
> 1lectroneuromyography
> /ootprint analyses
> #ait indexes
> (obility s+ill profiles
> 5bservations
> Photographic assessments
> %echnology-assisted assessments
> Qideographic assessments
> 0eight-bearing scales
> 0heelchair mobility tests
e. Sa$ety d"rin& &ait. l!c!+!ti!n. and (alance
> ,onfidence scales
> 'iaries
> /all scales
> /unctional assessment profiles
> )ogs
> *eports
%ools for gathering data may include:
a. ,atteries !$ tests
(. Ca+eras and ph!t!&raphs
c. Diaries
d. Dyna+!+eters
e. Electr!ne"r!+y!&raphs
$. ;!rce plat$!r+s
&. G!ni!+eters
h. Inde4es
i. In'ent!ries
=. L!&s
3. B!ti!n analysis syste+s
l. O(ser'ati!ns
+. P!st"ral c!ntr!l tests
n. Pr!$iles
!. Ratin& scales
p. Rep!rts
>. Scales
r. Techn!l!&y/assisted analysis syste+s
s. Gide! ca+eras and 'ide!tapes
'ata generated are used in providing documentation and may include:
a. Descripti!ns !$:
> #ait and locomotion
> #ait, locomotion, and balance characteristics with or without the use of devices
or equipment
> #ait, locomotion, and balance on and in different physical environments
> )evel of safety during gait, locomotion, and balance
> 3tatic and dynamic balance
> 0heelchair maneuverability and mobility
%:. Inte&"+entary Inte&rity
Integumentary integrity
> Is the intactness of the s+in, including the ability of the s+in to serve as a barrier
to environmental threats (eg, bacteria, parasites!
%he physical therapist uses these tests and measures to assess the effects of a wide
variety of disorders that result in s+in and subcutaneous changes, including:
> Pressure and vascular, venous, arterial, diabetic, and necropathic ulcers
> 9urns and other traumas, and
> & number of diseases (eg, soft tissue disorders!
/or associated s+in, tests and measures may include those that characterize or
quantify:
a. Acti'ities. p!siti!nin&. and p!st"res that pr!d"ce !r relie'e tra"+a t! the
s3in
> 5bservations
> Pressure-sensing maps
> 3cales
(. Assisti'e. adapti'e. !rth!tic. pr!tecti'e. s"pp!rti'e. !r pr!sthetic de'ices
!r e>"ip+ent that +ay pr!d"ce !r relie'e tra"+a t! the s3in
> 5bservations
> Pressure-sensing maps
> *is+ assessment scales
c. S3in characteristics. incl"din& (listerin&. c!ntin"ity !$ s3in c!l!r.
der+atitis. hair &r!)th. +!(ility. nail &r!)th. te+perat"re. te4t"re. and
t"r&!r
> 5bservations
> Palpation
> Photographic assessments
> %hermography
/or wound(s!, tests and measures may include those that characterize or quantify:
a. Acti'ities. p!siti!nin&. and p!st"res that a&&ra'ate the )!"nd !r scar !r
that pr!d"ce !r relie'e tra"+a
> 5bservations
> Pressure-sensing maps
(. ,"rn
> 9ody charting
> Planimetry
c. Si&ns !$ in$ecti!n
> ,ultures
> 5bservations
> Palpation
d. !"nd characteristics. incl"din& (leedin&. c!ntracti!n. depth. draina&e.
e4p!sed anat!+ical str"ct"res. l!cati!n. !d!r. pi&+ent. shape. siAe.
sta&in& and pr!&ressi!n. t"nnelin&. and "nder+inin&
> 'igital and grid measurement
> #rading of sores and ulcers
> 5bservations
> Palpation
> Photographic assessments
> 0ound tracing
e. !"nd scar tiss"e characteristics. incl"din& (andin&. plia(ility. sensati!n.
and te4t"re
> 5bservations
> 3car-rating scales
%ools for gathering data may include:
a. Ca+eras and ph!t!&raphs
(. Charts
c. C"lt"re 3its
d. Grids
e. O(ser'ati!ns
$. Palpati!n
&. Plani+eters
h. Press"re/sensin& de'ices
i. R"lers
=. Scales
3. Ther+!&raphs
l. Tracin&s. +aps. &raphs
/or associated s+in, data generated are used in providing documentation and may
include:
a. Descripti!ns !$ acti'ities and p!st"res that a&&ra'ate !r relie'e s3in
tra"+a
(. Descripti!ns and >"anti$icati!ns !$ s3in characteristics
c. Descripti!ns !$:
> 9lister
> 'evices and equipment that may produce s+in trauma
> Gair pattern
> 3+in color and continuity
/or wound(s!, data generated are used in providing documentation and may include:
a. Descripti!ns !$ acti'ities and p!st"res that a&&ra'ate !r relie'e )!"nd !r
scar tra"+a
(. Descripti!ns !$ si&ns !$ in$ecti!n
c. Descripti!ns and >"anti$icati!ns !$:
> 9urn (eg, size, type, depth!
> 0ound characteristics
> 0ound scar tissue characteristics
%%. E!int Inte&rity and B!(ility
Loint integrity
> Is the intactness of the structure and shape of the -oint, including its
osteo+inematic and arthro+inematic characteristics
> %he tests and measures of -oint integrity assess the anatomic and biomechanical
components of the -oint
Loint mobility
> Is the capacity of the -oint to be moved passively, ta+ing into account the
structure and shape of the -oint surface in addition to characteristics of the tissue
surrounding the -oint
> %he tests and measures of -oint mobility assess the performance of accessory
-oint movements, which are not under voluntary control
%he physical therapist uses these tests and measures to assess whether there is
excessive motion (hypermobility! or limited motion (hypomobility! of the -oint
%ests and measures may include those that characterize or quantify:
a. E!int inte&rity and +!(ility
> &pprehension, compression and distraction, drawer, glide, impingement, shear,
and valgus$varus stress tests
> &rthrometry
> Palpation
(. E!int play +!'e+ents. incl"din& end $eel -all =!ints !$ the a4ial and
appendic"lar s3elet!n0
> Palpation
c. Speci$ic (!dy parts
> &pprehension, compression and distraction, drawer, glide, impingement, shear,
and valgus$varus stress tests
> &rthrometry
%ools for gathering data may include:
a. Arthr!+eters
(. Apprehensi!n tests
c. C!+pressi!n and distracti!n tests
d. Dra)er tests
e. Glide tests
$. I+pin&e+ent tests
&. Palpati!n
h. Shear tests
i. Gal&"s<'ar"s stress tests
'ata generated are used in providing documentation and may include:
a. Descripti!ns !$:
> &ccessory motion
> 9ony and soft tissue restrictions during movement
(. Descripti!ns !r >"anti$icati!ns !$ =!int hyp!+!(ility !r hyper+!(ility
c. Presence !$:
> &pprehension
> Loint impingement
d. Presence and se'erity !$ a(n!r+al =!int artic"lati!n
%*. B!t!r ;"ncti!n -B!t!r C!ntr!l and B!t!r Learnin&0
(otor function
> Is the ability to learn or demonstrate the s+illful and efficient assumption,
maintenance, modification, and control of voluntary postures and movement
patterns
%he physical therapist uses these tests and measures in the assessment of
wea+ness, paralysis, dysfunctional movement patterns, abnormal timing, poor coordination,
clumsiness, atypical movements, or dysfunctional postures
%ests and measures may include those that characterize or quantify:
a. De4terity. c!!rdinati!n. and a&ility
> ,oordination screens
> (otor impairment tests
> 5bservations
> Qideographic assessments
(. Electr!physi!l!&ical inte&rity
> 1lectroneuromyography
c. Hand $"ncti!n
> /ine and gross motor control tests
> /inger dexterity tests
> (anipulative ability tests
> 5bservations
d. Initiati!n. +!di$icati!n. and c!ntr!l !$ +!'e+ent patterns and '!l"ntary
p!st"res
> &ctivity indexes
> 'evelopmental scales
> #ross motor function profiles
> (otor scales
> (ovement assessment batteries
> 8euromotor tests
> 5bservations
> Physical performance tests
> Postural challenge tests
> Qideographic assessments
%ools for gathering data may include:
a. ,atteries !$ tests
(. De4terity tests
c. Electr!ne"r!+y!&raphs
d. ;"ncti!n tests
e. Hand +anip"lati!n tests
$. Inde4es
&. B!t!r per$!r+ance tests
h. O(ser'ati!ns
i. P!st"ral challen&e tests
=. Pr!$iles
3. Scales
l. Screens
+. Tilt (!ards
n. Gide! ca+eras and 'ide!tapes
'ata generated are used in providing documentation and may include:
a. Descripti!ns and >"anti$icati!ns !$:
> 'exterity, coordination, and agility
> Gand movements
> Gead, trun+, and limb movements
> 3ensorimotor integration
> Qoluntary, age-appropriate postures and movement patterns
(. O(ser'ati!ns and descripti!ns !$ atypical +!'e+ents
c. #"anti$icati!ns !$ electr!physi!l!&ical resp!nses t! sti+"lati!n
%1. B"scle Per$!r+ance -Incl"din& Stren&th. P!)er. and End"rance0
(uscle performance
> Is the capacity of a muscle or a group of muscles to generate forces
3trength
> Is the muscle force exerted by a muscle or a group of muscles to overcome a
resistance under a specific set of circumstances
Power
> Is the wor+ produced per unit of time or the product of strength and speed
1ndurance
> Is the ability of muscle to sustain forces repeatedly or to generate forces over a
period of time
%he muscle force that can be measured depends on the interrelationships among
such factors such as the length of the muscle, the velocity of the muscle contraction, and the
mechanical advantage
*ecruitment of motor units, fuel storage, and fuel delivery, in addition to balance,
timing, and sequencing of contraction, mediate integrated muscle performance
%he physical therapist uses these tests and measures to determine the ability to
produce, maintain, sustain, and modify movements that are prerequisite to functional recovery
%ests and measures may include those that characterize or quantify:
a. Electr!physi!l!&ical inte&rity
> 1lectroneuromyography
(. B"scle stren&th. p!)er. and end"rance
> 'ynamometry
> (anual muscle tests
> (uscle performance tests
> Physical capacity tests
> %echnology-assisted assessments
> %imed activity tests
c. B"scle stren&th. p!)er. and end"rance d"rin& $"ncti!nal acti'ities
> &ctivities of daily living (&')! scales
> /unctional muscle tests
> Instrumental activities of daily living (I&')! scales
> 5bservations
> Qideographic assessments
d. B"scle tensi!n
> Palpation
%ools for gathering data may include:
a. Dyna+!+eters
(. Electr!ne"r!+y!&raphs
c. ;"ncti!nal +"scle tests
d. Ban"al +"scle tests
e. B"scle per$!r+ance tests
$. O(ser'ati!ns
&. Palpati!n
h. Physical capacity tests
i. Scales
=. Sphy&+!+an!+eters
3. Techn!l!&y/assisted analysis syste+s
l. Ti+ed acti'ity tests
+. Gide! ca+eras and 'ide!tapes
'ata generated are used in providing documentation and may include:
a. CharacteriAati!ns !$:
> 1lectrophysiological responses to stimulation
> (uscle strength, power, and endurance
(. Presence and se'erity !$ pel'ic/$l!!r +"scle )ea3ness
c. #"anti$icati!ns !$:
> )evels of excitability of muscle
> (uscle strength, wor+, and power
%2. Ne"r!+!t!r De'el!p+ent and Sens!ry Inte&rati!n
8euromotor development
> Is the acquisition and evolution of movement s+ills throughout the life span
3ensory integration
> Is the ability to integrate information that is derived from the environment and that
relates to movement
%he physical therapist uses tests and measures to characterize movement s+ills in
infants, children, and adults
%he physical therapist also uses tests and measures to assess:
> (obility
> &chievement of motor milestones
> Postural control
> Qoluntary and involuntary movement
> 9alance
> *ighting and equilibrium reactions
> 1ye-hand coordination, and
> 5ther movement s+ills
%ests and measures may include those that characterize or quantify:
a. Ac>"isiti!n and e'!l"ti!n !$ +!t!r s3ills. incl"din& a&e/appr!priate
de'el!p+ent
> &ctivity indexes
> 'evelopmental inventories and questionnaires
> Infant and toddler motor assessments
> )earning profiles
> (otor function tests
> (otor proficiency assessments
> 8euromotor assessments
> *eflex tests
> 3creens
> Qideographic assessments
(. Oral +!t!r $"ncti!n. ph!nati!n. and speech pr!d"cti!n
> Interviews
> 5bservations
c. Sens!ri+!t!r inte&rati!n. incl"din& p!st"ral. e>"ili(ri"+. and ri&htin&
reacti!ns
> 9ehavioral assessment scales
> (otor and processing s+ill tests
> 5bservations
> Postural challenge tests
> *eflex tests
> 3ensory profiles
> Qisual perceptual s+ill tests
%ools for gathering data may include:
a. ,atteries !$ tests
(. ,eha'i!ral assess+ent scales
c. Electr!physi!l!&ical tests
d. Inde4es
e. Inter'ie)s
$. In'ent!ries
&. B!t!r assess+ent tests
h. B!t!r $"ncti!n tests
i. Ne"r!+!t!r assess+ents
=. O(ser'ati!ns
3. P!st"ral challen&e tests
l. Pr!$iciency assess+ents
+. Pr!$iles
n. #"esti!nnaires
!. Re$le4 tests
p. Scales
>. Screens
r. S3ill tests
s. Gide! ca+eras and 'ide!tapes
'ata generated are used in providing documentation and may include:
a. Descripti!ns and >"anti$icati!ns !$:
> 9ehavioral response to stimulation
> 'exterity, coordination, and agility
> (ovement s+ills, including age-appropriate development, gross and fine motor
s+ills, reflex development
> 5ral motor function, phonation, and speech production
> 3ensorimotor integration, including postural, equilibrium, and righting reactions
(. O(ser'ati!ns and descripti!n !$ atypical +!'e+ent
%5. Orth!tic. Pr!tecti'e. and S"pp!rti'e De'ices
5rthotic, protective, and supportive devices
> &re implements and equipment used to support or protect wea+ or ineffective
-oints or muscles and serve to enhance performance
5rthotic devices include:
> 9races
> ,asts
> 3hoe inserts
> 3plints
Protective devices include:
> 9races
> ,ushions
> Gelmets
> Protective taping
3upportive devices include:
> ,ompression garments
> ,orsets
> 1lastic wraps
> (echanical ventilators
> 8ec+ collars
> 3erial casts
> 3lings
> 3upplemental oxygen
> 3upportive taping
%he physical therapist uses these tests and measures to assess the need for devices
in patients$clients not currently using them and to evaluate the appropriateness and fit of those
devices already in use
%ests and measures may include those that characterize or quantify:
a. C!+p!nents. ali&n+ent. $it. and a(ility t! care $!r the !rth!tic. pr!tecti'e.
and s"pp!rti'e de'ices and e>"ip+ent
> Interviews
> )ogs
> 5bservations
> Pressure-sensing maps
> *eports
(. Orth!tic. pr!tecti'e. and s"pp!rti'e de'ices and e>"ip+ent "se d"rin&
$"ncti!nal acti'ities
> &ctivities of daily living (&')! scales
> /unctional scales
> Instrumental activities of daily living (I&')! scales
> Interviews
> 5bservations
> Profiles
c. Re+ediati!n !$ i+pair+ents. $"ncti!nal li+itati!ns. !r disa(ilities )ith "se
!$ !rth!tic. pr!tecti'e. and s"pp!rti'e de'ices and e>"ip+ent
> &ctivity status indexes
> &') scales
> &erobic capacity tests
> /unctional performance inventories
> Gealth assessment questionnaires
> I&') scales
> Pain scales
> Play scales
> Qideographic assessments
d. Sa$ety d"rin& "se !$ !rth!tic. pr!tecti'e. and s"pp!rti'e de'ices and
e>"ip+ent
> 'iaries
> /all scales
> Interviews
> )ogs
> 5bservations
> *eports
%ools for gathering data may include:
a. Aer!(ic capacity tests
(. Diaries
c. Inde4es
d. Inter'ie)s
e. In'ent!ries
$. L!&s
&. O(ser'ati!ns
h. Play scales
i. Press"re/sensin& de'ices
=. Pr!$iles
3. #"esti!nnaires
l. Rep!rts
+. Scales
n. Gide! ca+eras and 'ide!tapes
'ata generated are used in providing documentation and may include:
a. Descripti!ns !$:
> &bility to use and care for devices and equipment
> &lignment and fit of the devices and equipment
> ,omponents of orthotic, protective, and supportive devices and equipment
> )evel of safety with devices and equipment
> Practicality of devices and equipment
> *emediation of impairment, functional limitation, or disability with use of devices
and equipment
(. #"anti$icati!ns !$:
> (ovement patterns with or without devices
> Physiological and functional effect and benefit of devices and equipment
%6. Pain
Pain
> Is a disturbed sensation that causes suffering or distress
%he physical therapist uses these tests and measures to determine a cause or a
mechanism for the pain and to assess the intensity, quality, and temporal and physical
characteristics of any pain that is important to the patient and that may result in impairments,
functional limitations, or disabilities
%ests and measures may include those that characterize or quantify:
a. Pain. s!reness. and n!cicepti!n
> &ngina scales
> &nalog scales
> 'iscrimination tests
> 'yspnea scales
> Pain drawings and maps
> Provocation tests
> Qerbal and pictorial descriptor tests
(. Pain in speci$ic (!dy parts
> Pain indexes
> Pain questionnaires
> 3tructural provocation tests
%ools for gathering data may include:
a. Descript!r tests -'er(al and pict!rial0
(. Discri+inati!n tests
c. Inde4es
d. Pain dra)in&s and +aps
e. Pr!'!cati!n and str"ct"ral pr!'!cati!n tests
$. #"esti!nnaires
&. Scales
'ata generated are used in providing documentation and may include:
a. CharacteriAati!ns !$ acti'ities !r p!st"res that a&&ra'ate !r relie'e pain
(. Descripti!ns and >"anti$icati!ns !$ pain acc!rdin& t! speci$ic (!dy part
c. L!caliAati!n !$ pain
d. Sens!ry and te+p!ral >"alities !$ pain
e. Se'erity !$ pain. s!reness. and disc!+$!rt
$. S!+atic distri("ti!n !$ pain
%7. P!st"re
Posture
> Is the alignment and positioning of the body in relation to gravity, center of mass,
or base of support
%he physical therapist uses these tests and measures to assess structural alignment
#ood posture
> Is a state of musculos+eletal balance that protects the supporting structures of
the body against in-ury or progressive deformity
%ests and measures may include those that characterize or quantify:
a. P!st"ral ali&n+ent and p!siti!n -dyna+ic0. incl"din& sy++etry and
de'iati!n $r!+ +idline
> 5bservations
> %echnology-assisted assessments
> Qideographic assessments
(. P!st"ral ali&n+ent and p!siti!n -static0. incl"din& sy++etry and de'iati!n
$r!+ +idline
> #rid measurement
> 5bservations
> Photographic assessments
c. Speci$ic (!dy parts
> &ngle assessments
> /orward-bending test
> #oniometry
> 5bservations
> Palpation
> Positional tests
%ools for gathering data may include:
a. An&le assess+ents
(. Ca+eras and ph!t!&raphs
c. G!ni!+eters
d. Grids
e. O(ser'ati!ns
$. Palpati!n
&. P!siti!nal tests
h. Pl"+( lines
i. Tape +eas"res
=. Techn!l!&y/assisted analysis syste+s
3. Gide! ca+eras and 'ide!tapes
'ata generated are used in providing documentation and may include:
a. #"anti$icati!ns !$:
> 'ynamic alignment, symmetry, and deviation during movement
> Postural alignment using posture grids
> 3tatic alignment, symmetry, and deviation
%8. Pr!sthetic Re>"ire+ents
Prosthetic requirements
> &re the biomechanical elements necessitated by the loss of a body part
Prosthesis
> Is an artificial device used to replace a missing part of the body
%he physical therapist uses these tests and measures to assess the effects and
benefits, components, alignment and fit, and safe use of the prosthesis
%ests and measures may include those that characterize or quantify:
a. C!+p!nents. ali&n+ent. $it. and a(ility t! care $!r the pr!sthetic de'ice
> Interviews
> )ogs
> 5bservations
> Pressure-sensing maps
> *eports
(. Pr!sthetic de'ice "se d"rin& $"ncti!nal acti'ities
> &ctivities of daily living (&')! scales
> /unctional scales
> Instrumental activities of daily living (I&')! scales
> Interviews
> 5bservations
c. Re+ediati!n !$ i+pair+ents. $"ncti!nal li+itati!ns. !r disa(ilities )ith "se
!$ pr!sthetic de'ice
> &erobic capacity tests
> &ctivity status indexes
> &') scales
> /unctional performance inventories
> Gealth assessment questionnaires
> I&') scales
> Pain scales
> Play scales
> %echnology-assisted assessments
> Qideographic assessments
d. Resid"al li+( !r ad=acent se&+ent. incl"din& ede+a. ran&e !$ +!ti!n. s3in
inte&rity. and stren&th
> #oniometry
> (uscle tests
> 5bservations
> Palpation
> Photographic assessments
> 3+in integrity tests
> %echnology-assisted assessments
> Qideographic assessments
> Qolume measurement
e. Sa$ety d"rin& "se !$ the pr!sthetic de'ice
> 'iaries
> /all scales
> Interviews
> )ogs
> 5bservations
> *eports
%ools for gathering data may include:
a. Aer!(ic capacity tests
(. Ca+eras and ph!t!&raphs
c. Diaries
d. G!ni!+eters
e. Inde4es
$. Inter'ie)s
&. In'ent!ries
h. L!&s
i. B"scle tests
=. O(ser'ati!ns
3. Palpati!n
l. Press"re/sensin& de'ices
+. Pr!$iles
n. #"esti!nnaires
!. Rep!rts
p. Scales
>. S3in inte&rity tests
r. Techn!l!&y/assisted analysis syste+s
s. Gide! ca+eras and 'ide!tapes
t. G!l"+!+eters
'ata generated are used in providing documentation and may include:
a. Descripti!ns and >"anti$icati!ns !$:
> &bility to use and care for device and practicality of device
> ,omponents of prosthetic devices
> )evel of safety with device
> *esidual limb or ad-acent segment
(. Descripti!ns and >"anti$icati!ns !$:
> &lignment and fit of the device
> *emediation of impairment, functional limitation, or disability with device
c. #"anti$icati!ns !$:
> (ovement patterns with or without device
> Physiological and functional effects and benefits of device
%9. Ran&e !$ B!ti!n -Incl"din& B"scle Len&th0
*ange of motion (*5(!
> Is the arc through which movement occurs at a -oint or a series of -oints
(uscle length
> Is the maximum of extensibility of a muscle-tendon unit
> In con-unction with -oint integrity and soft tissue extensibility, determines flexibility
%he physical therapist uses these tests and measures to assess the range of motion
of a -oint
%ests and measures may include those that characterize or quantify:
a. ;"ncti!nal ROB
> 5bservations
> 3quat testing
> %oe touch tests
(. E!int acti'e and passi'e +!'e+ent
> #oniometry
> Inclinometry
> 5bservations
> Photographic assessments
> %echnology-assisted assessments
> Qideographic assessments
c. B"scle len&th. s!$t tiss"e e4tensi(ility. and $le4i(ility
> ,ontracture tests
> #oniometry
> Inclinometry
> )igamentous tests
> )inear measurement
> (ultisegment flexibility tests
> Palpation
%ools for gathering data may include:
a. ,ac3 ROB de'ices
(. Ca+eras and ph!t!&raphs
c. Cer'ical pr!tract!rs
d. ;le4i(le r"lers
e. ;"ncti!nal tests
$. G!ni!+eters
&. Inclin!+eters
h. Li&a+ent!"s stress tests
i. B"ltise&+ent $le4i(ility tests
=. O(ser'ati!ns
3. Palpati!n
l. Sc!li!+eters
+. Tape +eas"res
n. Techn!l!&y/assisted analysis syste+s
!. Gide! ca+eras and 'ide!tapes
'ata generated are used in providing documentation and may include:
a. Descripti!ns !$ +"scle. =!int. and s!$t tiss"e characteristics
(. O(ser'ati!ns and descripti!ns !$ $"ncti!nal !r +"ltise&+ent +!'e+ent
c. #"anti$icati!ns !$:
> (usculotendinous extensibility *5(
*:. Re$le4 Inte&rity
*eflex integrity
> Is the intactness of the neural path involved in a reflex
*eflex
> Is a stereotypic, involuntary reaction to any of a variety of sensory stimuli
%he physical therapist uses these test and measures to determine the excitability of
the nervous system and the integrity of the neuromuscular system
%ests and measures may include those that characterize or quantify:
a. Deep re$le4es
> (yotatic reflex scale
> 5bservations
> *eflex tests
(. Electr!physi!l!&ical inte&rity
> 1lectroneuromyography
c. P!st"ral re$le4es and reacti!ns. incl"din& ri&htin&. e>"ili(ri"+. and
pr!tecti'e reacti!ns
> 5bservations
> Postural challenge tests
> *eflex profiles
> Qideographic assessments
d. Pri+iti'e re$le4es and reacti!ns. incl"din& de'el!p+ental
> *eflex profiles
> 3creening tests
e. Resistance t! passi'e stretch
> %one scales
$. S"per$icial re$le4es and reacti!ns
> 5bservations
> Provocation tests
%ools for gathering data may include:
a. Electr!ne"r!+y!&raphs
(. By!tatic re$le4 scales
c. O(ser'ati!ns
d. P!st"ral challen&e tests
e. Pr!'!cati!n tests
$. Re$le4 pr!$iles
&. Re$le4 tests
h. Scales
i. Screens
=. Gide! ca+eras and 'ide!tapes
'ata generated are used in providing documentation and may include:
a. CharacteriAati!ns and >"anti$icati!ns !$:
> &ge-appropriate reflexes
> 'eep reflexes
> 1lectrophysiological responses to stimulation
> Postural reflexes and righting reactions
> 3uperficial reflexes
*%. Sel$/care and H!+e Bana&e+ent -Incl"din& Acti'ities !$ Daily Li'in& and
Instr"+ental Acti'ities !$ Daily Li'in&0
3elf-care management
> Is the ability to perform activities of daily living (&')!, such as bed mobility,
transfers, dressing, grooming, bathing, eating, and toileting
Gome management
> Is the ability to perform instrumental activities of daily living (I&')!, such as
structured play (for infants and children!, maintaining a home, shopping,
performing household chores, caring for dependents, and performing yard wor+
%he physical therapist uses the results of these tests and measures to assess:
> %he level of performance of tas+s necessary for independent living
> %he need for assistive, adaptive, orthotic, protective, supportive, or prosthetic
devices or equipment4 and
> %he need for body mechanics training, organized functional training programs, or
therapeutic exercise
%ests and measures may include those that characterize or quantify:
a. A(ility t! &ain access t! h!+e en'ir!n+ents
> 9arrier identification
> 5bservations
> Physical performance tests
(. A(ility t! per$!r+ sel$/care and h!+e +ana&e+ent acti'ities )ith !r
)ith!"t assisti'e. adapti'e. !rth!tic. pr!tecti'e. s"pp!rti'e. !r pr!sthetic
de'ices !r e>"ip+ent
> &') scales
> &erobic capacity tests
> I&') scales
> Interviews
> 5bservations
> Profiles
c. Sa$ety in sel$/care and h!+e +ana&e+ent acti'ities and en'ir!n+ents
> 'iaries
> /all scales
> Interviews
> )ogs
> 5bservations
> *eports
> Qideographic assessments
%ools for gathering data may include:
a. Aer!(ic capacity tests
(. ,arrier identi$icati!n chec3lists
c. Diaries
d. ;all scales
e. Inde4es
$. Inter'ie)s
&. In'ent!ries
h. L!&s
i. O(ser'ati!ns
=. Physical per$!r+ance tests
3. Pr!$iles
l. Rep!rts
+. #"esti!nnaires
n. Scales
!. Gide! ca+eras and 'ide!tapes
'ata generated are used in providing documentation and may include:
a. Descripti!ns and >"anti$icati!ns !$:
> &bility to participate in variety of environments
> /unctional capacity
> )evel of safety in self-care and home management activities
> 8eed for devices or equipment
> Physiological responses to activity
**. Sens!ry Inte&rity
3ensory integrity
> Is the intactness of cortical sensory processing, including proprioception,
pallesthesia, sterognosis, and topognosis
Proprioception
> Is the reception of stimuli from within the body (eg, from muscles and tendons!
and includes position sense (the awareness of -oint position! and +inesthesia (the
awareness of movement!
Pallesthesia
> Is the ability to sense mechanical vibration
3tereognosis
> Is the ability to perceive, recognize, and name familiar ob-ects
%opognosis
> Is the ability to localize exactly a cutaneous sensation
%he physical therapist uses the results of tests and measures to determine the
integrity of the sensory, perceptual, and somatosensory processes
%ests and measures may include those that characterize or quantify:
a. C!+(ined c!rtical sensati!ns
> 3tereognosis tests
> %actile discrimination tests
(. Deep sensati!ns
> Tinesthesiometry
> 5bservations
> Photographic assessments
> Qibration tests
c. Electr!physi!l!&ical inte&rity
> 1lectroneuromyography
%ools for gathering data may include:
a. Ca+eras and ph!t!&raphs
(. Esthesi!+eters
c. Electr!ne"r!+y!&raphs
d. ;ila+ents
e. Oinesthesi!+eters
$. O(ser'ati!ns
&. Palpati!n
h. Press"re scales
i. Sens!ry tests
=. T"nin& $!r3s
'ata generated are used in providing documentation and may include:
a. CharacteriAati!ns and >"anti$icati!ns !$:
> 1lectrophysiological responses to stimulation
> Position and movement sense
> 3ensory processing
> 3ensory responses to provocation
*1. Gentilati!n and Respirati!n<Gas E4chan&e
Qentilation
> Is the movement of a volume of gas into and out of the lungs
*espiration
> Is the exchange of oxygen and carbon dioxide across a membrane either in the
lungs or at the cellular level
%he physical therapist uses these tests and measures to determine whether the
patient has an adequate ventilatory pump and oxygen upta+e$carbon dioxide elimination system
to meet the oxygen demands at rest, during aerobic exercise, and during the performance of
activities of daily living
%ests and measures may include those that characterize or quantify:
a. P"l+!nary si&ns !$ respirati!n<&as e4chan&e. incl"din& (reath s!"nds
> #as analyses
> 5bservations
> 5ximetry
(. P"l+!nary si&ns !$ 'entilat!ry $"ncti!n. incl"din& air)ay pr!tecti!n?
(reath and '!ice s!"nds? respirat!ry rate. rhyth+. and pattern? 'entilat!ry
$l!). $!rces. and '!l"+es
> &irway clearance tests
> 5bservations
> Palpation
> Pulmonary function tests
> Qentilatory muscle force tests
c. P"l+!nary sy+pt!+s
> 'yspnea and perceived exertion indexes and scales
%ools for gathering data may include:
a. Air)ay clearance tests
(. ;!rce +eters
c. Gas analyses
d. Inde4es
e. O(ser'ati!ns
$. Palpati!n
&. P"lse !4i+eters
h. Spir!+eters
i. Steth!sc!pes
'ata generated are used in providing documentation and may include:
a. Descripti!ns and characteriAati!n !$:
> 9reath and voice sounds
> ,hest wall and related structures
> Phonation
> Pulmonary-related symptoms
> Pulmonary vital signs
> %horacoabdominal ventilatory patterns
(. O(ser'ati!ns and descripti!ns !$ nail (eds
c. Presence and le'el !$ cyan!sis
d. #"anti$icati!ns !$:
> &bility to clear and protect airway
> #as exchange and oxygen transport
> Pulmonary function and ventilatory mechanics
*2. !r3 -E!(<Sch!!l<Play0. C!++"nity. and Leis"re Inte&rati!n !r Reinte&rati!n
-incl"din& Instr"+ental Acti'ities !$ Daily Li'in&0
0or+ (-ob$school$play! integration or reintegration
> Is the process of assuming or resuming roles and functions at wor+
(-ob$school$play!, such as negotiating school environments, gaining access to
wor+ (-ob$school$play! environments and wor+stations, and participating in age-
appropriate play activities
,ommunity integration or reintegration
> Is the process of assuming or resuming roles and functions in the community,
such as gaining access to transportation (eg, driving a car, boarding a bus,
negotiating a neighborhood!, to community businesses and services (eg, ban+,
shops, par+s!, and to public facilities (eg, attending theaters, town hall
meetings, and places of worship!
)eisure integration or reintegration
> Is the process of assuming or resuming roles and functions of avocational and
en-oyable pastimes, such as recreational activities (eg, playing a sport!, and
age-appropriate hobbies (eg, collecting antiques, gardening, or ma+ing crafts!
%he physical therapist uses the results of wor+, community, and leisure integration or
reintegration tests and measures to:
> (a+e -udgments as to whether a patient$client is currently prepared to assume or
resume community or wor+ (-ob$school$play! roles, including all instrumental
activities of daily living (I&')!
> 'etermine when and how such integration or reintegration might occur, or
> &ssess the need for assistive, adaptive, orthotic, protective, supportive, or
prosthetic devices or equipment
%he physical therapist also uses the results of these tests and measures to
determine whether the patient$client is a candidate for a wor+ hardening or wor+ conditioning
program
%ests and measures may include those that characterize or quantify:
a. A(ility t! ass"+e !r res"+e )!r3 -=!(<sch!!l<play0. c!++"nity. and leis"re
acti'ities )ith !r )ith!"t assisti'e. adapti'e. !rth!tic. pr!tecti'e.
s"pp!rti'e. !r pr!sthetic de'ices and e>"ip+ent
> &ctivity profiles
> 'isability indexes
> /unctional status questionnaires
> I&') scales
> 5bservations
> Physical capacity tests
(. A(ility t! &ain access t! )!r3 -=!(<sch!!l<play0. c!++"nity. and leis"re
en'ir!n+ents
> 9arrier identification
> Interviews
> 5bservations
> Physical capacity tests
> %ransportation assessments
c. Sa$ety in )!r3 -=!(<sch!!l<play0. c!++"nity. and leis"re en'ir!n+ents
> 'iaries
> /all scales
> Interviews
> )ogs
> 5bservations
> Qideographic assessments
%ools for gathering data may include:
a. Diaries
(. Inde4es
c. Inter'ie)s
d. L!&s
e. O(ser'ati!ns
$. Physical capacity tests
&. Pr!$iles
h. #"esti!nnaires
i. Transp!rtati!n assess+ents
=. Scales
3. Gide! ca+eras and 'ide!tapes
'ata generated are used in providing documentation and may include:
a. Descripti!ns !$:
> )evel of safety in wor+ (-ob$school$play!, community, and leisure activities
> Physiological responses to activity
(. #"anti$icati!ns !$:
> &bility to participate in variety of environments
> /unctional capacity
> 8eed for devices or equipment
G. Physical Therapy Dia&n!stic Classi$icati!ns
Accordin- to the Preferred Practice "ettin-s in APTAs Guide to Physical Therapist Practice
A. B"sc"l!s3eletal
Primary prevention$ris+ reduction for s+eletal demineralization
Impaired posture
Impaired muscle performance
Impaired -oint mobility, motor function, muscle performance, and range of motion
associated with connective tissue dysfunction
Impaired -oint mobility, motor function, muscle performance, and range of motion
associated with localized inflammation
Impaired -oint mobility, motor function, muscle performance, range of motion, and
reflex integrity associated with spinal disorders
Impaired -oint mobility, muscle performance, and range of motion associated with
fracture
Impaired -oint mobility, motor function, muscle performance, and range of motion
associated with -oint arthroplasty
Impaired -oint mobility, motor function, muscle performance, and range of motion
associated with bony or soft tissue surgery
Impaired motor function, muscle performance, range of motion, gait, locomotion,
and balance associated with amputation
,. Ne"r!+"sc"lar
Primary prevention$ris+ reduction for loss of balance and falling
Impaired neuromotor development
Impaired motor function and sensory integrity associated with nonprogressive
disorders of the central nervous system 6 congenital origin or acquired in infancy
or childhood
Impaired motor function and sensory integrity associated with nonprogressive
disorders of the central nervous system 6acquired in infancy or childhood
Impaired motor function and sensory integrity associated with nonprogressive
disorders of the central nervous system 6 congenital origin or acquired in
adolescence or adulthood
Impaired motor function and sensory integrity associated with progressive
disorders of the central nervous system
Impaired peripheral nerve integrity and muscle performance associated with
peripheral nerve in-ury
Impaired motor function and sensory integrity associated with acute or chronic
polyneuropathies
Impaired motor function, peripheral nerve integrity, and sensory integrity
associated with nonprogressive disorders of the spinal cord
Impaired arousal, range of motion, and motor control associated with coma, near
coma, or vegetative state
C. Cardi!'asc"lar<P"l+!nary
Primary prevention$ris+ reduction for cardiovascular$pulmonary disorders
Impaired aerobic capacity$endurance associated with deconditioning
Impaired ventilation, respiration$gas exchange and aerobic capacity$endurance
associated with airway clearance dysfunction
Impaired aerobic capacity$endurance associated with cardiovascular pump
dysfunction or failure
Impaired ventilation and respiration$gas exchange associated with ventilatory
pump dysfunction or failure
Impaired ventilation and respiration$gas exchange associated with respiratory
failure
Impaired ventilation, respiration$gas exchange and aerobic capacity$endurance
associated with respiratory failure in the neonate
Impaired circulation and anthropometric dimensions associated with lymphatic
system disorders
D. Inte&"+entary
Primary prevention$ris+ reduction for integumentary disorders
Impaired integumentary integrity associated with superficial s+in involvement
Impaired integumentary integrity associated with partial-thic+ness s+in
involvement and scar formation
Impaired integumentary integrity associated with full-thic+ness s+in involvement
and scar formation
Impaired integumentary integrity associated with s+in involvement extending into
fascia, muscle, or bone and scar formation
GI. Physical Therapy Inter'enti!ns
Accordin- to APTAs Guide to Physical Therapist Practice
A. C!!rdinati!n. C!++"nicati!n. and D!c"+entati!n
&dministrative and supportive processes intended to ensure that patients$clients
receive appropriate, comprehensive, efficient, and effective quality of care from
admission through discharge
%. C!!rdinati!n @ the )!r3in& t!&ether !$ all parties in'!l'ed )ith the
patient<client.
*. C!++"nicati!n @ the e4chan&e !$ in$!r+ati!n.
1. D!c"+entati!n @ any entry int! the patient<client rec!rd that identi$ies the care
!r ser'ice pr!'ided.
Physical therapists are responsible for coordination, communication, and
documentation across all settings for all patients$clients
(ay include:
%. Addressin& Re>"ired ;"ncti!ns
&dvanced care directives
Individualized educational plans (l1Ps! or individualized family service plans (I/3Ps!
Informed consent
(andatory communication and reporting (eg, patient advocacy and abuse
reporting!
*. Ad+issi!n and Dischar&e Plannin&
1. Case Bana&e+ent
2. C!lla(!rati!n and C!!rdinati!n )ith A&encies. incl"din&:
1quipment suppliers
Gome care agencies
Payer groups
3chools
%ransportation agencies
5. C!++"nicati!n Acr!ss Settin&s. incl"din&:
,ase conferences
'ocumentation
1ducation plans
6. C!st/e$$ecti'e Res!"rce UtiliAati!n
7. Data C!llecti!n. Analysis. and Rep!rtin&
5utcome data
Peer review findings
*ecord reviews
8. D!c"+entati!n Acr!ss Settin&s -$!ll!)in& APTACs G"idelines $!r Physical
Therapy D!c"+entati!n0. incl"din&:
,hanges in impairments, functional limitations, and disabilities
,hanges in interventions
1lements of patient$client management (examination, evaluation, diagnosis,
prognosis, intervention!
5utcomes of intervention
9. Interdisciplinary Tea+)!r3
,ase conferences
Patient care rounds
Patient$client family meetings
%:. Re$errals t! Other Pr!$essi!nals !r Res!"rces
,. Patient<Client/related Instr"cti!n
%he process of informing, educating, or training patients$clients families,
significant others, and caregivers intended to promote and optimize physical
therapy services
Instruction may be related to:
%. the c"rrent c!nditi!n -e.&.. speci$ic i+pair+ents. $"ncti!nal li+itati!ns. !r
disa(ilities0
*. the plan !$ care
1. the need $!r enhanced per$!r+ance
2. transiti!n t! a di$$erent r!le !r settin&
5. ris3 $act!rs $!r de'el!pin& a pr!(le+ !r dys$"ncti!n
6. the need $!r health. )ellness. !r $itness pr!&ra+s
Physical therapists are responsible for patient$client-related instruction across all
settings for all patients$clients
(ay include:
%. Instr"cti!n. Ed"cati!n. and Trainin& !$ Patients<Clients and Care&i'ers
re&ardin&
,urrent condition (pathology$pathophysiology `disease, disorder, or conditiona,
impairments, functional limitations, or disabilities!
1nhancement of performance
Gealth, wellness, and fitness programs
Plan of care
*is+ factors for pathology$ pathophysiology (disease, disorder, or condition!,
impairments, functional limitations, or disabilities
%ransitions across settings
%ransitions to new roles
C. Pr!ced"ral Inter'enti!ns
%he physical therapy procedures and techniques, which include:
%. Therape"tic E4ercise
%he systematic performance or execution of planned physical movements, or
activities intended to enable the patient$client to:
a. Re+ediate !r pre'ent i+pair+ents
(. Enhance $"ncti!n
c. Red"ce ris3
d. Opti+iAe !'erall health
e. Enhance $itness and )ell/(ein&
(ay include:
a. Aer!(ic capacity<end"rance c!nditi!nin& !r rec!nditi!nin&
(. ,alance. c!!rdinati!n. and a&ility trainin&
c. ,!dy +echanics and p!st"ral sta(iliAati!n
d. ;le4i(ility e4ercises
e. Gait and l!c!+!ti!n trainin&
$. Ne"r!+!t!r de'el!p+ent trainin&
&. Rela4ati!n
h. Stren&th. p!)er. and end"rance trainin& $!r head. nec3. li+(. pel'ic/$l!!r.
tr"n3. and 'entilat!ry +"scles
*. ;"ncti!nal Trainin& in Sel$/care and H!+e Bana&e+ent -incl"din& ADL
and IADL0
%he education and training of patients$clients in activities of daily living (&')! and
instrumental activities of daily living (I&')! intended to improve the ability to perform physical
actions, tas+s, or activities in an efficient, typically expected, or competent manner
(ay include:
a. ADL trainin&
(. ,arrier acc!++!dati!ns !r +!di$icati!ns
c. De'ice and e>"ip+ent "se and trainin&
d. ;"ncti!nal trainin& pr!&ra+s
e. IADL trainin&
$. In="ry pre'enti!n !r red"cti!n
3elf-care includes &'), such as:
a. ,ed +!(ility
(. Trans$ers
c. Dressin&
d. Gr!!+in&
e. ,athin&
$. Eatin&
&. T!iletin&
Gome management includes more complex I&'), such as:
a. Carin& $!r dependents
(. Baintainin& a h!+e
c. Per$!r+in& h!"seh!ld ch!res and yard )!r3
d. Sh!ppin&
e. Str"ct"red play -$!r in$ants and children0
1. ;"ncti!nal Trainin& in !r3 -E!(<Sch!!l<Play0. C!++"nity. and Leis"re
Inte&rati!n and Reinte&rati!n -incl"din& IADL. !r3 Hardenin&. and !r3
C!nditi!nin&0
%he education and training of patients$clients in assumption and resumption of roles
and functions in the wor+ environment, in the community, and during leisure activities so that:
a. the physical acti!ns !r acti'ities re>"ired $!r these r!les and $"ncti!ns are
per$!r+ed in an e$$icient. typically e4pected. !r c!+petent +anner
(. the e4pectati!ns !$ -=!(<sch!!l<play0. c!++"nity. and leis"re r!les are
$"l$illed
(ay include:
a. ,arrier acc!++!dati!ns !r +!di$icati!ns
(. De'ice and e>"ip+ent "se and trainin&
> &ssistive and adaptive device or equipment training during I&')
> 5rthotic, protective, or supportive device or equipment training during I&')
> Prosthetic device or equipment training during I&')
c. ;"ncti!nal trainin& pr!&ra+s
> 9ac+ schools
> Lob coaching
> 3imulated environments and tas+s
> %as+ adaptation
> %as+ training
> %ravel training
> 0or+ conditioning
> 0or+ hardening
d. IADL trainin&
> ,ommunity service training involving instruments
> 3chool and play activities training including tools and instruments
> 0or+ training with tools
e. In="ry pre'enti!n !r red"cti!n
> In-ury prevention education during wor+ (-ob$school$play!, community, and leisure
integration or reintegration
> In-ury prevention education with use of devices and equipment
> 3afety awareness during wor+ (-ob$school$play!, community, and leisure
integration or reintegration
$. Leis"re and play acti'ities and trainin&
0or+ integration or reintegration into roles may include functions such as:
a. Gainin& access t! )!r3 -=!(<sch!!l<play0 en'ir!n+ents and )!r3stati!ns
(. Participatin& in )!r3 hardenin& !r )!r3 c!nditi!nin& pr!&ra+s
c. Ne&!tiatin& sch!!l en'ir!n+ents
d. Participatin& in a&e/appr!priate play acti'ities
0or+ integration or reintegration activities may include:
a. Acc!++!dati!ns t! !r +!di$icati!ns !$ en'ir!n+ental and )!r3 (arriers
(. ;"ncti!nal trainin& pr!&ra+s -e.&.. )!r3 hardenin& !r c!nditi!nin&
pr!&ra+s0
c. G"idance and instr"cti!n in in="ry pre'enti!n !r red"cti!n
d. E!( c!achin&
e. Leis"re and play acti'ity trainin&
$. Trainin& in IADL
&. Tas3 si+"lati!n and adaptati!n
h. Trainin& in the "se !$ assisti'e. adapti'e. !rth!tic. pr!tecti'e. s"pp!rti'e.
!r pr!sthetic de'ices and e>"ip+ent d"rin& )!r3 -=!(<sch!!l<play0.
c!++"nity. and leis"re acti'ities
i. Tra'el trainin&
,ommunity integration or reintegration into roles may include activities such as
gaining access to:
a. Transp!rtati!n -e.&.. dri'in& a car. (!ardin& a ("s0
(. A nei&h(!rh!!d -e.&.. ne&!tiatin& c"r(s. cr!ssin& streets0
c. C!++"nity ("sinesses and ser'ices -e.&.. (an3in&. sh!ppin&0
d. P"(lic $acilities -e.&.. attendin& theaters. t!)n hall +eetin&s. and places !$
)!rship0
)eisure integration or reintegration is the process of assuming or resuming roles and
functions of avocational and en-oyable pastimes, such as:
a. Recreati!nal acti'ities -e.&.. playin& a sp!rt0
(. A&e/appr!priate h!((ies -e.&.. c!llectin& anti>"es. &ardenin&. !r +a3in&
cra$ts0
2. Ban"al Therapy Techni>"es
3+illed hand movements intended to:
a. I+pr!'e tiss"e e4tensi(ility
(. Increase ran&e !$ +!ti!n
c. Ind"ce rela4ati!n
d. B!(iliAe !r +anip"late s!$t tiss"e and =!ints
e. B!d"late pain
$. Red"ce s!$t tiss"e s)ellin&. in$la++ati!n. !r restricti!n
(ay include:
a. Ban"al ly+phatic draina&e
(. Ban"al tracti!n
c. Bassa&e
> ,onnective tissue massage
> %herapeutic massage
d. B!(iliAati!n<+anip"lati!n
> 3oft tissue
> 3pinal and peripheral -oints
e. Passi'e ran&e !$ +!ti!n
5. Prescripti!n. Applicati!n. and. as Appr!priate. ;a(ricati!n !$ De'ices and
E>"ip+ent -Assisti'e. Adapti'e. Orth!tic. Pr!tecti'e. S"pp!rti'e. and
Pr!sthetic0
Processes to select, provide, and train for utilization of therapeutic implements and
equipment that are intended to:
a. Aid patients<clients in per$!r+in& tas3s and +!'e+ents
(. S"pp!rt )ea3 !r ine$$ecti'e =!ints !r +"scles and ser'e t! enhance
per$!r+ance
c. Replace a +issin& part !$ the (!dy
d. Adapt the en'ir!n+ent t! $acilitate $"ncti!nal per$!r+ance !$ acti'ities
related t! sel$/care. h!+e +ana&e+ent. )!r3. c!++"nity. and leis"re
(ay include:
a. Adapti'e de'ices
> 1nvironmental controls
> Gospital beds
> *aised toilet seats
> 3eating systems
(. Assisti'e de'ices
> ,anes
> ,rutches
> )ong-handled reachers
> Percussors and vibrators
> Power devices
> 3tatic and dynamic splints
> 0al+ers
> 0heelchairs
c. Orth!tic de'ices
> 9races
> ,asts
> 3hoe inserts
> 3plints
d. Pr!sthetic de'ices -l!)er/e4tre+ity and "pper/e4tre+ity0
e. Pr!tecti'e de'ices
> 9races
> ,ushions
> Gelmets
> Protective taping
$. S"pp!rti'e de'ices
> ,ompression garments
> ,orsets
> 1lastic wraps
> (echanical ventilators
> 8ec+ collars
> 3erial casts
> 3lings
> 3upplemental oxygen
> 3upportive taping
6. Air)ay Clearance Techni>"es
& group of therapeutic activities intended to manage or prevent the consequences of
impaired mucociliary transport or the inability to protect the airway (eg, impaired cough!
(ay include:
a. ,reathin& strate&ies
> &ctive cycle of breathing or forced expiratory techniques
> &ssisted cough$huff techniques
> &utogenic drainage
> Paced breathing
> Pursed lip breathing
> %echniques to maximize ventilation (eg, maximum inspiratory hold, stair case
breathing, manual hyperinflation!
(. Ban"al<+echanical techni>"es
> &ssistive devices
> ,hest percussion, vibration, and sha+ing
> ,hest wall manipulation
> 3uctioning
> Qentilatory aids
c. P!siti!nin&
> Positioning to alter wor+ of breathing
> Positioning to maximize ventilation and perfusion
> Pulmonary postural drainage
7. Inte&"+entary Repair and Pr!tecti!n Techni>"es
%he application of therapeutic procedures and modalities that are intended to:
a. Enhance )!"nd per$"si!n
(. Bana&e scar
c. Pr!+!te an !pti+al )!"nd en'ir!n+ent
d. Re+!'e e4cess e4"dates $r!+ a )!"nd c!+ple4
e. Eli+inate n!n'ia(le tiss"e $r!+ a )!"nd (ed
(ay include:
a. De(ride+ent @ n!nselecti'e
> 1nzymatic debridement
> 0et dressings
> 0et-to-dry dressings
> 0et-to-moist dressings
(. De(ride+ent @ selecti'e
> 'ebridement with other agents (eg, autolysis!
> 1nzymatic debridement
> 3harp debridement
> 'ressings
> Gydrogels
> Qacuum-assisted closure
> 0ound coverings
c. O4y&en therapy
> 3upplemental
> %opical
d. T!pical a&ents
> ,leansers
> ,reams
> (oisturizers
> 5intments
> 3ealants
e. Orth!tic. pr!tecti'e. and s"pp!rti'e de'ices
$. Physical a&ents and +echanical and electr!therape"tic +!dalities
8. Electr!therape"tic B!dalities
& broad group of agents that use electricity and are intended to:
a. Assist $"ncti!nal trainin&
(. Assist +"scle $!rce &enerati!n and c!ntracti!n
c. Decrease "n)anted +"sc"lar acti'ity
d. Increase the rate !$ healin& !$ !pen )!"nds and s!$t tiss"e
e. Baintain stren&th a$ter in="ry !r s"r&ery
$. B!d"late !r decrease pain
&. Red"ce !r eli+inate s!$t tiss"e s)ellin&. in$la++ati!n. !r restricti!n
%he use of electrotherapeutic modalities in the absence of other interventions should
not be considered physical therapy unless there is documentation that -ustifies the necessity of
their exclusive use
(ay include:
a. ,i!$eed(ac3
(. Electr!therape"tic deli'ery !$ +edicati!ns
> Iontophoresis
c. Electrical sti+"lati!n
> 1lectrical muscle stimulation (1(3!
> 1lectrical stimulation for tissue repair (13%*!
> /unctional electrical stimulation (/13!
> Gigh voltage pulsed current (GQP,!
> 8euromuscular electrical stimulation (8(13!
> %ranscutaneous electrical nerve stimulation (%183!
9. Physical A&ents and Bechanical B!dalities
Physical agents 6 a broad group of procedures using various forms of energy that
are applied to tissues in a systemic manner and that are intended to:
a. Increase c!nnecti'e tiss"e e4tensi(ility
(. Increase the healin& rate !$ !pen )!"nds and s!$t tiss"e
c. B!d"late pain
d. Red"ce !r eli+inate s!$t tiss"e s)ellin&. in$la++ati!n. !r restricti!n
ass!ciated )ith +"sc"l!s3eletal in="ry !r circ"lat!ry dys$"ncti!n
e. Re+!del scar tiss"e
$. Treat s3in c!nditi!ns
(ay include:
a. Ather+al a&ents
> Pulsed electromagnetic fields
(. Cry!therapy
> ,old pac+s
> Ice massage
> Qapocoolant spray
c. Hydr!therapy
> ,ontrast bath
> Pools
> Pulsatile lavage
> 0hirlpool tan+s
d. Li&ht a&ents
> Infrared
> )&31*
> 2ltraviolet
e. S!"nd a&ents
> Phonophoreseis
> 2ltrasound
$. Ther+!therapy
> 'ry heat
> Got pac+s
> Paraffin baths
(echanical modalities 6 a group of devices that use forces such as approximation,
compression, and distraction and that are intended to:
a. I+pr!'e circ"lati!n
(. Increase ran&e !$ +!ti!n
c. B!d"late pain
d. Sta(iliAe an area that re>"ires te+p!rary s"pp!rt
(ay include:
a. C!+pressi!n therapies
> ,ompression bandaging
> ,ompression garments
> %aping
> %otal contact casting
> Qasopneumatic compression devices
(. Gra'ity/assisted c!+pressi!n de'ices
> 3tanding frame
> %ilt table
c. Bechanical +!ti!n de'ices
> ,ontinuous passive motion (,P(!
d. Tracti!n de'ices
> Intermittent
> Positional
> 3ustained
%he use of physical agents or mechanical modalities in the absence of other
interventions should not be considered physical therapy unless there is documentation that
-ustifies the necessity of their exclusive use