EWU Department of Physical Therapy
CI Weekly Planning Form for PHTH 581
Clinical Internship I (PHTH 581) consists of a full time experience in a clinical setting for 5
(five) weeks during summer session of the first year of the DPT Program. The primary
purposes are to provide patient centered care by demonstrating examination, evaluation
and intervention skills learned in the first academic year, professional behaviors and
professional interactions with patients and health care professionals in the clinical
environment.
The list below includes the skills taught in the Program during the first year. The student
needs opportunities to practice these basic skills with patients with supervision and
feedback from you. Remember, the student has not had all of the academics in
neuromuscular, cardiopulmonary or musculoskeletal systems beyond the basic skills listed;
therefore, he/she is not prepared to perform all examination techniques or to complete
evaluations independently.
Evaluation of the student will include the use of the weekly planning forms for weeks 1 – 4
and completion of the Clinical Performance Instrument (CPI) during week 5. The student will
self-assess using the same forms and the CPI.
The student will:
Demonstrate patient safety, appropriate universal precautions and sterile technique.
Assess cardiovascular/pulmonary tests and measures: heart rate, pulse oximetry,
respiratory rate, blood pressure and visual signs (SOB, paleness, nausea, diaphoresis).
Perform musculoskeletal system tests and measures: MMTing, palpation, ROM,
goniometry.
Review pertinent medical records.
Conduct a patient interview.
Perform sensory integrity tests and measures.
Write a legible progress note with correct format, abbreviations and content.
Write measurable functional goals that are time referenced with expected outcomes.
Perform posture and gait analysis.
Perform transfer training.
Actively participate in, plan and advance treatment interventions.
Apply superficial and deep heat and cold modalities.
Perform massage.
Perform electrical stimulation for pain management and motor control.
Perform extremity mobilizations (shoulder, fingers, knee and ankle).
Participate in discharge planning.
These weekly planning forms for students and for CIs can be completed in hard copy format
or downloaded from the website. www.ewu.edu/pt Go to clinical education to current
students or to clinical faculty.
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EWU Department of Physical Therapy
CI Weekly Planning Form for PHTH 581
Week #1
Comments (done, in process,
progressing, needs work)
Orientation to facility and staff
Discuss learning style
Discuss expectations
Actively participates in patient exam, interventions and
documentation
Demonstrates safety with patient care
Demonstrates professional interactions with patients and staff
Chose one assignment for completion during week 2
Wrote specific goals for next week
My evaluation of the student’s performance this week is:
For week 2, the student needs to work on:
My evaluation was reviewed by the student.
3/15/2010
Date
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EWU Department of Physical Therapy
CI Weekly Planning Form for PHTH 581
Week 2
Comments (done, in process,
progressing, needs work)
Actively participates in patient exam, interventions and
documentation
Demonstrates safety with patient care
Demonstrates professional interactions with patients and
staff
Review week 2 goals: met or not met and why
Assignment for week 2 completed?
Wrote specific goals for week 3
Chose one assignment for completion during week 3
My evaluation of the student’s performance this week is:
For week 3, the student needs to work on:
My evaluation was reviewed by the student.
3/15/2010
Date
Page 3
EWU Department of Physical Therapy
CI Weekly Planning Form for PHTH 581
Week #3
Comments (done, in process,
progressing, needs work)
Actively participates in patient exam, interventions and
documentation
Demonstrates safety with patient care
Demonstrates professional interactions with patients and
staff
Review week 3 goals: met or not met and why
Assignment for week 3 completed?
Wrote specific goals for week 4
Chose one assignment for completion during week 4
My evaluation of the student’s performance this week is:
For week 4, the student needs to work on:
My evaluation was reviewed by the student.
3/15/2010
Date
Page 4
EWU Department of Physical Therapy
CI Weekly Planning Form for PHTH 581
Week #4
Comments (done, in process,
progressing, needs work)
Actively participates in patient exam, interventions and
documentation
Demonstrates safety with patient care
Demonstrates professional interactions with patients and
staff
Review week 4 goals: met or not met and why
Assignment for week 4 completed?
Wrote specific goals for week 5
Begin working on CPI for completion during week 5
My evaluation of the student’s performance this week is:
For week 5, the student needs to work on:
My evaluation was reviewed by the student.
3/15/2010
Date
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EWU Department of Physical Therapy
CI Weekly Planning Form for PHTH 581
Assignment list:
Choose one of these assignments or one that your CI requests.
1. Complete a structured observation with another healthcare professional. Download the
structured observation form from the EWU PT Clinical Education website to use as a
guide. Submit the form to the DCE with your final documentation.
2. During week 1 or 2, create a list of how you will demonstrate initiative during this
internship. Give the list to your CI. During the final week, assess how you actually
demonstrated initiative.
3. Compare and contrast the plan of care for two patients with similar diagnoses. Within
one minute, verbally report your findings to your CI.
4. Identify the resources that a patient needs for return to work/school/play. Share your
list with the patient and get his/her feedback.
5. Identify the barriers to a patient’s return to work/school/play. Discuss the list with your
CI.
6. During week one write measurable functional short term and long term goals for a
patient. Give your goals to your CI. During week four or five, write measurable
functional short term and long term goals for a patient with a similar diagnosis. Ask
your CI for your week 1 goals. Compare/contrast them with the week 4 or 5 goals.
Identify the components of goal writing that show improvement.
7. Take vital signs on 5 different patients. Compare the results and identify normal vs.
pathology.
8. Choose an exercise program that you are doing with a patient. Write a modification of
the exercise program to make it less challenging and more challenging.
9. Choose an exercise program that you are doing with a patient. Write down how you
would modify the exercise program if the patient had an additional comorbidity
(diabetes, CVA, cognitive deficit, etc.).
10. Verbally describe to your CI in a concise manner the resources that you used to make a
clinical decision.
11. Find two research articles for your CI that are relevant to the management of patients
you are seeing.
12. Explain the impact of a patient’s medication on your intervention or on the patient’s
response to your intervention to your CI in a concise manner.
13. After interviewing a patient, consider if you asked the patient all of the necessary
questions. Write down any additional questions you might ask during the next visit.
14. Tell your CI what you did today that made you feel like a physical therapist?
15. Assess how your non-verbal communication during a patient treatment helped or
hindered the session. Discuss your observation with your CI and describe what you will
do differently during the next treatment session.
www.ewu.edu/pt
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