Medical Record, Patient Education,
Patient Rapport
PTP 641
Medical Surgical Physical Therapy Exam and POC
Chart Review
Documentation
Initial Exams/Chart Reviews
Daily Notes
Progress Notes
Discharge Summaries
Chart Review
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Why perform a chart review?
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For new eval
For treatment from last PT note
Face Sheet
History and Physical (H&P)
Consults
Orders/Referrals
Physician Progress Notes
ER Services Record
Nursing Vital Sign Flow Sheet
Meds
Nursing Intake Sheet
Labs, Diagnostic Test Results
Operative Report
Documentation
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New Eval (as you review the chart, complete the form or take notes)
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History
Face Sheet, H&P, Consults, Orders, Physician and Nursing Notes, ER/OR Reports, Lab
Values, Diagnostic Results
Ask Nursing for clarification
Face to face discussion with the patient/family to clarify information or dwell deeper
into an area of importance
Tests & Measures
Screens and then choose the most appropriate measurements
Document it was a screen, location, pt position, etc
Most PTs initiate some form of interventions (pt education, 1-2 ther ex, mobility)
PT Dx with prognosis
Recommendations – discharge/equipment and why
Goals
Plan of Care
Write the overall plan but last thing is to include a specific plan
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Ex. Continue with general mobility, balance activities, endurance and strength of R LE.
Focus on hip precautions and check pulse ox with activity, assess strength of quads and DFs.
Documentation
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Daily Note
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Progress Note
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SOAP format
Always document “Assessment” (Progression, regression or plateau)
and address goals
Every 3-5 sessions the PT must write a progress note
Simple addendum to a daily note written by another PT or PTA OR
PT is the person to provide care that day.
Overview of how the pt is progressing and why, what goals the pt is
progressing towards or regressing or at a plateau – what to continue
with for a POC
Discharge Summary
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PT Dept policy is no discharge summary because pt’s are discharged
and charts are broken down immediately OR electronic account is
not accessible.
Check with clinical instructor or health system as a new grad
Communication
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Nursing
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Physician
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Other consults/referrals
CNA (Certified Nursing Assistant)
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How the patient performed
Mobility
Other Disciplines
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OT, SLP, PTA
Case Manager – equipment, d/c plans
Social Worker – coping, d/c to SNF
Patient Care
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Eval
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Screens
Functional Mobility
Outcome Measure
Initiate HEP or treatment
Pt Care
 Chart Review
 History or Brief
 Measurements
Questions
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Screens or repeated measurements
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Function or Exercise
 Procedural
 Tolerance
 Closing the
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Interventions
session
Review therapy performed in the session
Pt satisfaction
Summarize overall goals
Perform HEP or next session
Patient Education
Is the Patient Receptive?
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Pt’s State of Mind-Affective
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Pain
Acute Stage of Disease/Disorder
Medication
Loss of Body Part
Disfigurement
Changes in Tissue
Impairments/Body Structure and Function
Functional Limitations/Activity Limitations
Disability/Participation Limitations
Contextual/Psychosocial
Coping
Quick Check During Examination
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Relevant to conversation
Orientation
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Alertness
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Alert to lethargy
Follow commands
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Person, Place, Time, Situation
Number of steps
Simple problem solving skills
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Simple math, reasoning
Quick Check During Examination
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Communication
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Make needs known
Language
Learning Style
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Educational needs
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Written, auditory, pictures, kinesthetics
Learning barriers
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HOH, legally blind, literacy
“Move Forward”
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Precautions/Contraindications
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Safety, Use of device, Fine tune movement
Disease Process
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Strength, Endurance, Balance, etc
Modifications
Mobility Training Instruction
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Watch Out versus Don’t Do
Therapeutic Exercise
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(APTA)
Prevention, modifications, if progressive, prevention
Discharge Destinations
Safety in the Home or Discharge Destination
HEP: “Make It Work”
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Fit into the day
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Give only three to five exercises or points
Easy numbers to remember
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Three times per day
Revolve around meal times
Simple to remember
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(Tim Gunn)
Reps in 5’s, 10s
Position of patient
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Ankle pumps: in supine, sit (open or closed chain)
Quad strength: quad set in supine, LAQ in sitting,
mini-squats in standing
Information
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Handouts
Booklets
Exercise Sheets
Journals/Logs
Pictures
Patient Rapport
Interpersonal Skills
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Good verbal and nonverbal skills
Listening skills – the pt is the only thing in the world
and you have their undivided attention
Knock prior to entering
Introduce Self
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Address with title “Mr/Mrs/Ms”
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Student PT and why you are there
Ask to call by first name or nickname
Write down “parking lot” list and address the items
on the list
Respect Wishes
Respect Diversity
Interpersonal Skills
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Dimensions of Patient Care
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Respect Me As A Person
Relieve My Fears
Provide Me Comfort and Pain Relief
Involve My Family and Friends
Coordinate My Care
Treat Me As A Person, Not As An Episode
Give Me Predictive Information
Provide Me Access
Patient Rights
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Advanced Directives
Confidentiality
Consents and Refusals
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Pt Rights: The pt has the right to refuse
Pt Responsibilities: The pt has the responsibility to follow
physician’s plan of care
Risks and Benefits