Evaluation
Though the physical examination of infants and children is based
on the same principles as those employed in the adults' examination, the
approach to the patient and the interpretation of findings may be entirely
different. The pediatric patient is not merely a small adult. Rather, he is a
dynamic developing individual and his examination must be based and
interpreted on a thorough knowledge of normal growth and development.
Definition of evaluation:
It is an observational study of a subject, carrying out a specific
task. It is a continuing process of collecting and organizing information in
order to plan and implement effective treatment.
Importance of evaluation:
- To set up a good relationship with the child.
- To identify or rule out the existence of a specific problem.
- To provide diagnostic information.
- To plan a treatment program.
- To identify areas of progress or lack of progress.
- To determine the patient's status at the time of discharge and the type of
follow-up plan.
Pre-requisites:
* Knowledge in the human biological, behavioral and motor development
as well as sequence of normal reflexive maturation.
* Rational and logical system of data acquisition (examination, sorting
and grouping).
* Organized observation is a must to view the client evaluation.
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Principles:
* Identifying abilities is important as well as identifying deficits.
* The determination of reasons of function and non-function is a part of
assessing performance.
* Assessment should be carried out as early as possible because of the
plasticity that exists in infants and young children. The development of
intellectual and emotional function is affected by the kind of sensory and
motor experiences provided from birth.
* Assessment should be repeated at intervals, as the child is a rapidly
changing organism.
* When the child is severely disabled, a number of people are involved in
his assessment.
* It is important to have few well-selected hidden toys to keep the child
interested and amused.
* Painful parts of examination must be left to the end of evaluation.
Types of evaluation:
Banus (1971) distinguished three types of assessment:
- Informal assessment: It is a general overview of the patient's
performance, made through observation in a non-structured manner. It is
mainly
used
to
locate
the
affected
part(s)
in
the
patient
(quick test).
- Formal assessment: It is organized for a structured presentation.
Individual tasks are chosen to elicit specific identifiable behavior
(functional test).
- Standardized assessment: It is a highly structured and strict procedure
as to presentation, timing and scoring. Normative data, gathered from the
testing of a sample of normal children are used for grading performance
(muscle test).
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Environmental conditions during evaluation:
- Undressing: Children below six years of age dislike being undressed
and get particularly tense, which may impede reliable evaluation. To
overcome this problem, let the mother undresses her child and do not
keep him undressed for a long period.
- Examination table: Children under six years of age are frightened by
examination tables, which are usually narrow, high and cold. As a result,
they are unable to relax, impeding the course of examination. A mat on
the floor often provides the best means of carrying out the examination.
- Examination room: It should be small, quiet, worm and restful. The
physical therapist may avoid the white coat if necessary and keep his
hands worm.
- Presence of the mother: The mother should be present when the child is
under six years of age.
- Relationship with the child: The physical therapist should not approach
the child directly but to observe him while talking with his parents until
the child familiarize himself with the environment.
Variability in assessment:
Repeated evaluation of an individual child within a short period of
time usually gives variable results. This is because the child observable
progress and performance are the result of unnumbered factors, both
internal and external.
Problems that may occur during evaluation:
During physical evaluation of children with multiple handicaps,
various problems may arise to challenge the assessor. Examples of these
problems are:
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* Assessment form: An important reason that you will find so many
evaluation forms and methods. Advice can be offered as to follow the
problem oriented medical recording system (POMR).
* Interaction with the child: Assessment should be done in an enjoyable
way and not too hard to perform. The child is let to demonstrate what he
can do first and not focusing on his deficits. The distracting materials
should be removed and the unnecessary sounds should be eliminated
from the environment. A reward system may be necessary.
* Parent's response to the evaluation results: The physical therapist must
be sensitive to the parent's response, as for some parents the reality
appears stressful and painful and cannot be easily accepted. The physical
therapist should widely maintain open channels to potential concern,
directing the parents to the best ways they can help at home but never to
give them false hope.
Styles of recording clinical evaluation:
1. Narrative notes: It is a story-telling generalized report.
2. Problem oriented medical record (POMR): This system is designed as
a plan for assembling patient’s data and organizing them by problem, thus
assuring a logical framework for the delivery of health care. It is an
orderly record-keeping system, designed to record and communicate the
process of patient’s care. It is superior to the narrative notes because it
has a definite format.
Advantages of POMR system:
- Detailed reminder of clinical and laboratory information and therapy.
- Source of information about the patient’s past illnesses and treatments.
- Easy communication with other medical staff members.
- Can be used easily in evaluation, treatment plan and clinical research.
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Elements of POMR system:
1. Data base.
2. Problem list.
3. Initial plan.
4. Progress notes.
1. Data base:
It includes all subjective and objective information that can be
gathered from the patient to form a broad base, from which the problem
could be easily identified.
Sources of data base:
a) Patient’s file: Through which the therapist can collect information
including history, laboratory data, medical condition, chief complaint,
patient’s present illness and physical examination.
b) Questioning: The therapist should ask the patient or his parents the
relevant questions to fill the gaps in the information collected from the
patient’s file and to know more about his condition.
c) Evaluation: The therapist will use the appropriate methods of
evaluation, according to the patient’s condition. It includes:
- Observation: General and specific of the position and movement.
- Palpation: To locate the affected area if can not be detected by sight.
- Measurements: Using tape, goniometer, electrical test, etc.
- Functional tests: to compare the patient’s functional abilities with the
standard tests according to age.
2. Problem list:
It is a collaborative tool, which may be formulated by physicians,
physical therapists or other health care professionals.
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- The problem list includes all the facts that contribute to the overall
picture of the patient’s condition found in the data base.
- Individual problems should be numbered chronologically.
- Each problem should be labeled as being active (not been solved) or
inactive (treated temporarily or permanently).
- Date of the initial problem should be recorded.
- Date of solving the problem should be recorded.
Example:
Problem no
Date
Active Problem
Date
Inactive Problem
1
10/09/2005
Drop right wrist
03/10/2005
Wrist splint
2
3
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3. Initial Plan:
* Emphasize what will be done for solving each problem.
* Each plan should have the same number as the problem it solves and
should be designed for each active problem.
* The initial plan should be realistic and aims at solving the problem
directly.
* It should be designed to reach one or more of the following aims:
a) More data: When the therapist needs more data before constructing a
plan. This data can be collected from observations, tests, symptoms and
interviews with the family.
b) Treatment: Different modalities which have direct effect in solving the
patient’s problem. Determine the number of sessions if it is allowed.
c) Home routine: This may be conducted and revised at regular intervals.
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4. Progress notes:
It includes the patient’s care, written under 4 headings.
S: Subjective: Description of the patient’s current functional disabilities
and symptoms.
O: Objective: Observation and records of any test, which may be
performed to confirm the subjective data.
A: Assessment: Concise statement of the situation as seen by the therapist
at that particular moment. It includes the update objectives of treatment.
P: Plan: It is used to indicate changes in the initial plan, including
cessation of a procedure due to changes in the patient’s problem.
Comparison between narrative notes and POMR notes
Narrative Notes
POMR
Organization
* No general format to guide documentation * Definite format with guidelines to
of clinical findings.
document clinical findings.
* Difficulty in seeking out information as a * Easy location of the information within a
result of "story telling" style.
familiar style.
* Time consuming; as there is a tendency to * Thorough, concise and orderly clinical
over-narrate (write too much).
findings. Easy reading and extraction of
information.
* Not comprehensive; as there is a tendency * Too little information is not a hazard if the
to under-narrate (write too little).
POMR format is followed.
* Poor communication of patient's status to * Easy communication of the patient's status
other members of the health care team.
to other members of the health care team.
* Poor planning for treatment as "clinical * "Clinical picture" is easily established and
picture" is not established and "prognosis" "progress" quickly noted.
poorly reported.
Utilization
* Progress reports if there is little or no * Initial evaluation and progress reports for
change in patient's status.
a patient, who is being seen regularly.
* If the patient is seen only once for a minor * A "one-visit consultation" for patient
problem.
evaluation and reporting recommendation to
a physician.
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