PT Fundamentals Week 1 - Patient Client Management Model Overview

Patient Client Management Model Steps

• Examination: Initiate a thorough assessment of each patient.
• Patient History: Collect information through chart review, focusing on red flags, chief complaints, medical and social history, and patient goals.
• Systems Review: Assess cardiopulmonary, integumentary, musculoskeletal, and neuromuscular systems.
• Obtain Outcome Measures: Quantify functional limitations to tailor the care plan.
• Hypothesis Formation: Use gathered data to create a working hypothesis regarding the condition.
• Referral/Consultation: Determine if collaboration with other healthcare providers is necessary.
• Evaluation: Analyze collected data to generate a problem list and establish a diagnosis and prognosis.
• Intervention: Develop a specific plan of care with defined goals for the patient's recovery.
• Outcomes: Measure and assess patient-specific outcomes to evaluate effectiveness.

Role in Physical Therapy Decision-Making

• The physical therapist is responsible for creating, managing, and being accountable for the plan of care.
• Defines scope for assistants and other support staff, ensuring clarity in roles during service delivery.
• Facilitates communication among various healthcare providers regarding management plans.

SOAP Note Documentation Components

• Subjective: Patient's self-report of symptoms, medical history, and goals.
• Objective: Measured data including tests, clinical observations, and interventions performed.
• Assessment: Clinical reasoning through subjective and objective data analysis to form opinions on conditions and progress.
• Plan: Outline treatment strategies, goals, expected outcomes, and coordination with other providers, including rehabilitation focus.

Importance of the SOAP Framework

• Enhances communication among healthcare providers, ensuring aligned treatment strategies.
• Supports continuity of care, impacting long-term treatment planning.
• Addresses legal and ethical standards in patient documentation.

Specific Information in Each SOAP Section

• Subjective: Collect patient demographics, current conditions, symptom behavior, levels of function, medical, and social histories.
• Objective: Document observations, specific tests/measures, clinical findings, and patient response to interventions.
• Assessment: Integrate subjective and objective data into coherent clinical reasoning, including diagnosis and prognosis.
• Plan: Comprehensive treatment plan, including goals, intervention strategies, timelines, and coordination with other services.

Applying SOAP Format to Patient Client Management Model

• Examination correlates to both the subjective and objective parts of the SOAP note, gathering detailed patient histories and system reviews.
• Evaluation/Prognosis/Diagnosis aligns with the assessment section where clinical reasoning and diagnostic conclusions are documented.
• Plan of Care is established in the plan section, setting concrete goals and interventions.

Initial Visit SOAP Documentation Emphasis

• Subjective Data: Focus on historical patient information, complaint details, symptom characteristics, and expectations for therapy.
• Objective Data: Capture all relevant measurements, system reviews, and clinical observations in a structured format to ensure clarity.

Treatment Visit SOAP Documentation Guidelines

• Subjective Section: Document patient's responses, symptom changes, ongoing challenges, and adherence to home exercise programs.
• Objective Section: Focus on therapist's measured outcomes, clinical interventions applied, and patient responses specific to the treatment session.

Goal Setting Principles (SMART)

• Specific: Clearly defined goals tailored to the patient's needs.
• Measurable: Quantitative criteria to assess progress.
• Achievable: Realistic targets based on the patient's capabilities.
• Relevant: Ensuring goals are valuable and beneficial to the patient.
• Time-based: Setting clear deadlines for when goals should be achieved.

Goal Writing Format (ABCDE)

• Actor: Identify who will accomplish the goal.
• Behavior: Define the action to be taken.
• Condition: Outline the circumstances under which the behavior is performed.
• Degree: Quantify the level of achievement required.
• Expected Time Frame: Specify when the goal should be met.### Treatment Session Parameters
• Utilize resistance of 3 x 10 with red theraband for strength training.
• Emphasize parameters: sets, repetitions, rest, recovery, and resistance levels.
• Define machine settings and patient positioning for effective treatment.

Equipment and Education

• Identify all equipment used during the session.
• Client and caregiver education is integrated as a crucial intervention strategy.

Interventions Overview

• Clearly define interventions performed within the session.
• Demonstrate technical skills required for patient care.
• Establish rationale for selected interventions to ensure clarity in practice.

Measurable Changes

• Track measurable changes post-treatment in relation to patient goals.
• Collect data reflecting patient-reported responses and observational outcomes.
• Documentation should include treatment responses and changes in measurements.

Documentation Guidelines

• Follow SOAP format for treatment visit documentation: Subjective, Objective, Assessment, and Plan.
• Outline essential components for each section ensuring defensible documentation reflecting skilled care.

Assessment and Progress

• Assessment should reflect clinical decision-making based on impairments and activity limitations.
• Document overall patient progression (improved, worsened, or unchanged) supported by subjective and objective data.
• Include relevant findings that may inform treatment choices and strategies.

Future Planning

• Provide specific follow-up plans detailing education for patient and caregivers.
• Include potential alterations in frequency, treatment adjustments, or discharge plans in documentation.

Mutual Understanding

• Ensure mutual understanding of subsequent actions among therapist and client.
• Determine if treatment will continue unchanged, with changes, or discontinue care entirely.

Language Accuracy

• Use precise language in documentation: avoid vagueness and ensure inclusion of essential components.
• Avoid overly broad statements like “continue”; instead, employ specific language indicating future treatment intentions.

This quiz focuses on the Patient Client Management Model, outlining the essential steps involved from initial examination to outcome assessment. Participants will explore the stages including patient history, systems review, and the assessment of movement to ensure a comprehensive understanding of patient management.